Provider Demographics
NPI:1750385415
Name:HINMAN, MARK WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALLACE
Last Name:HINMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 TULIP ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3140
Mailing Address - Country:US
Mailing Address - Phone:303-776-6872
Mailing Address - Fax:303-776-2501
Practice Address - Street 1:1350 TULIP ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3140
Practice Address - Country:US
Practice Address - Phone:303-776-6872
Practice Address - Fax:303-776-2501
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04021093Medicaid
COF55398Medicare UPIN
CO04021093Medicaid