Provider Demographics
NPI:1649803065
Name:DOLAND, MARK EUGENE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:DOLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2329
Mailing Address - Country:US
Mailing Address - Phone:515-697-7995
Mailing Address - Fax:515-288-9109
Practice Address - Street 1:2331 E 8TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-1715
Practice Address - Country:US
Practice Address - Phone:515-266-6338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAT18024101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)