Provider Demographics
NPI:1386622348
Name:DEKUTOSKI, MARK B (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:DEKUTOSKI
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 1:320 HARBOR BLVD UNIT 1205
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-7331
Mailing Address - Country:US
Mailing Address - Phone:507-319-4415
Mailing Address - Fax:
Practice Address - Street 1:320 HARBOR BLVD UNIT 1205
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-7331
Practice Address - Country:US
Practice Address - Phone:507-319-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145588207X00000X, 207XS0117X
AZ47104207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ47104OtherARIZONA MEDICAL BOARD
MN845382900Medicaid
AZ767459Medicaid
AZZ93326Medicare UPIN
MN200015080Medicare ID - Type UnspecifiedRAILROAD
MN200000661Medicare ID - Type Unspecified
MN845382900Medicaid