Provider Demographics
NPI:1528497393
Name:HOOTEN, MARK MITCHELL (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:MITCHELL
Last Name:HOOTEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 BONFOY AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-3804
Mailing Address - Country:US
Mailing Address - Phone:719-367-4406
Mailing Address - Fax:
Practice Address - Street 1:3141 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4094
Practice Address - Country:US
Practice Address - Phone:719-327-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2025-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203660207Q00000X
CODR.0056847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102203660OtherOSTEOPATHY & SURGERY
CO9000176240Medicaid
GA9000176240Medicaid