Provider Demographics
NPI:1073536439
Name:EARHART, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:EARHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1747 LANGFORD DR BLDG 400-105
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7370
Mailing Address - Country:US
Mailing Address - Phone:706-769-1100
Mailing Address - Fax:706-310-9847
Practice Address - Street 1:1747 LANGFORD DR BLDG 400-105
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7370
Practice Address - Country:US
Practice Address - Phone:706-769-1100
Practice Address - Fax:706-310-9847
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54770Medicare UPIN
GA08BBWSRMedicare ID - Type Unspecified