Provider Demographics
NPI:1578645230
Name:TOMASULO, MARK RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:TOMASULO
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 1:5994 HIGH NOON AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-5813
Mailing Address - Country:US
Mailing Address - Phone:706-575-3024
Mailing Address - Fax:
Practice Address - Street 1:5994 HIGH NOON AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-5813
Practice Address - Country:US
Practice Address - Phone:706-575-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS31852207Q00000X
CO48324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO307051Medicare PIN