Provider Demographics
NPI:1083684476
Name:FOSSEY, MARK DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:FOSSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21228
Mailing Address - Street 2:DEPARTMENT 31
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:918-491-3762
Mailing Address - Fax:918-491-5740
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:JACK C. MONTGOMERY VAMC
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:918-577-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK117932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100118230AMedicaid
OK$$$$$$$$$PMedicare PIN