Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | ME145588 | FL |
Y | 207XS0117X | Orthopaedic Spine Surgeon | ME145588 | FL |
NPI | 1386622348 |
---|---|
Provider Name | Mark B Dekutoski |
First Address | Destin, FL 32541-7331 |
Second Address | Destin, FL 32541-7331 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2006 |
Last Update Date | 25/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F32150 | (02) | |
Z93326 | (02) | AZ |