Provider Demographics
NPI:1982662102
Name:DONALDSON, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:DONALDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 111
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-8999
Practice Address - Fax:801-429-8063
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT1678601205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT03-00069OtherUNITED HEALTHCARE
UT070003257OtherPALMETTO GBA
UT870281028DO1OtherEMIA
UT107006212101OtherIHC HEALTHPLANS
UT4081OtherDMBA
UT6603OtherPEHP
UTQM0000037164OtherALTIUS
UT870281028DO1OtherEMIA
UT000000174Medicare PIN
UT070003257OtherPALMETTO GBA
UT6603OtherPEHP