Provider Demographics
NPI:1962472803
Name:PETRUN, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:PETRUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-224-9102
Mailing Address - Fax:970-224-9112
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:STE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-224-9102
Practice Address - Fax:970-224-9112
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0024745207RC0200X, 207RP1001X, 207RS0012X, 207R00000X
CO24745207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01247451Medicaid
WY104364100Medicaid
CO290007464OtherRAILROAD MEDICARE
WY104364100Medicaid
CO267024YLB8Medicare PIN
COD24508Medicare UPIN