Provider Demographics
NPI:1013196492
Name:MEMARK, VANCHAD C (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCHAD
Middle Name:C
Last Name:MEMARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RON
Other - Middle Name:C
Other - Last Name:MEMARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:148 BILL CARRUTH PKWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3754
Mailing Address - Country:US
Mailing Address - Phone:770-445-4915
Mailing Address - Fax:770-445-2876
Practice Address - Street 1:148 BILL CARRUTH PKWY
Practice Address - Street 2:SUITE 180
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3754
Practice Address - Country:US
Practice Address - Phone:770-445-4915
Practice Address - Fax:770-445-2876
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64416208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2949877Medicaid
OH2949877Medicaid
OHME4265911Medicare PIN