Provider Demographics
NPI:1902903198
Name:DUSTER, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:DUSTER
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 1:1400 E BOULDER ST
Mailing Address - Street 2:MEMORIAL CHILDRENS HOSPITAL
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-365-9543
Mailing Address - Fax:719-365-5530
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:MEMORIAL CHILDRENS HOSPITAL
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-9543
Practice Address - Fax:719-365-5530
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-09-05
Deactivation Date:2017-05-15
Deactivation Code:
Reactivation Date:2018-09-05
Provider Licenses
StateLicense IDTaxonomies
CO215212080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01215219Medicaid
CO01215219Medicaid
E46290Medicare UPIN
COCOAAA1341Medicare PIN