Provider Demographics
NPI:1144364936
Name:DE MARIE, MARK P (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:DE MARIE
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 1:1375 E 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-5422
Mailing Address - Country:US
Mailing Address - Phone:303-369-0710
Mailing Address - Fax:
Practice Address - Street 1:1375 E 20TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5423
Practice Address - Country:US
Practice Address - Phone:303-743-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO285462080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01285469Medicaid
004570OtherKAISER-COMMERCIAL NUMBER
CO01285469Medicaid
COCK10393Medicare PIN
COCOA105706Medicare PIN