Provider Demographics
NPI:1285616631
Name:MOUNTFORD, MARK C (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:MOUNTFORD
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 1:2530 N 8TH ST
Mailing Address - Street 2:101
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8857
Mailing Address - Country:US
Mailing Address - Phone:970-241-9729
Mailing Address - Fax:
Practice Address - Street 1:2635 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8209
Practice Address - Country:US
Practice Address - Phone:970-241-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO337852085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01337856Medicaid
COF59783Medicare UPIN
COC371148Medicare PIN