Provider Demographics
NPI:1972543197
Name:NAVILLIAT, MARK CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:NAVILLIAT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 S CHAMBERS RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-5073
Mailing Address - Country:US
Mailing Address - Phone:303-680-6121
Mailing Address - Fax:303-680-8627
Practice Address - Street 1:3451 S CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5073
Practice Address - Country:US
Practice Address - Phone:303-680-6121
Practice Address - Fax:303-680-8627
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2458174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCP4703Medicare ID - Type Unspecified