Provider Demographics
NPI:1255338174
Name:DESAUTEL, MARK GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GREGORY
Last Name:DESAUTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1310 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1501
Practice Address - Country:US
Practice Address - Phone:605-328-8200
Practice Address - Fax:605-328-8201
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4246207Y00000X, 207YP0228X, 207YS0123X, 207YX0602X, 207YX0901X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4996176OtherBLUE SHIELD
MN8015163000Medicaid
SD6520242Medicaid
IA1986174Medicaid
IAI5249005Medicare PIN
SDS41310Medicare PIN
IA1986174Medicaid
MN8015163000Medicaid
IA1986174Medicaid
MN8015163000Medicaid