Provider Demographics
NPI:1265434583
Name:DEPONTE, MARK DAVID (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:DEPONTE
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 1:2 LEE RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351
Mailing Address - Country:US
Mailing Address - Phone:860-376-4451
Mailing Address - Fax:860-376-5977
Practice Address - Street 1:2 LEE RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351
Practice Address - Country:US
Practice Address - Phone:860-376-4451
Practice Address - Fax:860-376-5977
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010039945CT01OtherBCBS
CT001399452Medicaid
020323907OtherCIGNA
2V1508OtherHEALTHNET
020323907OtherUNHC
080001555Medicare ID - Type Unspecified
020323907OtherUNHC