Provider Demographics
NPI:1972505725
Name:SILETCHNIK, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:SILETCHNIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1413 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-5251
Mailing Address - Country:US
Mailing Address - Phone:575-546-6548
Mailing Address - Fax:575-546-6540
Practice Address - Street 1:1413 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-5251
Practice Address - Country:US
Practice Address - Phone:575-546-6548
Practice Address - Fax:575-546-6540
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30952207V00000X
NM80-254207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG18932Medicare UPIN
NMGRP 300521051 NPIMedicare UPIN