Provider Demographics
NPI:1396737490
Name:ROBISON, MARK CHRISTIAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTIAN
Last Name:ROBISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:CHRIS
Other - Last Name:ROBISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1982 E VISCOUNTI CV
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1059
Mailing Address - Country:US
Mailing Address - Phone:612-990-6018
Mailing Address - Fax:
Practice Address - Street 1:1982 E VISCOUNTI CV
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-1059
Practice Address - Country:US
Practice Address - Phone:612-990-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170377-1205208000000X
UT170377-8905208000000X
MN42052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348321500Medicaid