Provider Demographics
NPI:1770540056
Name:IMMERGUT, MARK ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:IMMERGUT
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 1:6000 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3803
Mailing Address - Country:US
Mailing Address - Phone:301-468-8999
Mailing Address - Fax:
Practice Address - Street 1:6000 EXECUTIVE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3803
Practice Address - Country:US
Practice Address - Phone:301-468-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0008736208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD312564OtherOPTIMUM CHOICE PROVIDER #
DCV746 0014OtherBSDC
MD0715414OtherCIGNA PROVIDER NUMBER
MD521186611OtherUNITED HEALTHCARE PROV #
MDV746 0014OtherBSMD
MD312564OtherMDIPA PROVIDER NUMBER
MD312564OtherMAMSI PROVIDER NUMBER
MD312564OtherALLIANCE PROVIDER NUMBER
MD521186611OtherUNITED HEALTHCARE PROV #
MDB92878Medicare UPIN