Provider Demographics
NPI:1295993871
Name:ABBOTT, MARK FREDRIC (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDRIC
Last Name:ABBOTT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 N GREENWOOD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2655
Mailing Address - Country:US
Mailing Address - Phone:719-542-2167
Mailing Address - Fax:
Practice Address - Street 1:1619 N GREENWOOD ST STE 103
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2655
Practice Address - Country:US
Practice Address - Phone:719-542-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1490322085R0202X
UT8495680-12052085R0202X, 2085R0204X
CODR.00563802085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10000009999001OtherBCBSU
UT1295993871OtherEMI HEALTH
UT1295993871Medicaid
UT1295993871OtherMOLINA HEALTHCARE
UTP01180702OtherRAILROAD MEDICARE
UT107120161102OtherSELECTHEALTH
UT1137616OtherDMBA
UT4697935OtherAETNA HEALTHCARE
UT145448OtherPEHP
UT145448OtherPEHP