Basic Information
| Provider Information | |||||||||
| NPI: | 1255338174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESAUTEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 W 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288200 | ||||||||
| FaxNumber: | 6053288201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4246 | SD | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | 4246 | SD | N | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YS0123X | 4246 | SD | N | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0602X | 4246 | SD | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207YX0901X | 4246 | SD | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207YX0905X | 4246 | SD | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4996176 | 01 | SD | BLUE SHIELD | OTHER | 8015163000 | 05 | MN | MEDICAID | 6520242 | 05 | SD | MEDICAID | 1986174 | 05 | IA | MEDICAID |