Provider Demographics
NPI:1104825637
Name:BUCHANAN, MARK GARY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GARY
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2687 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-572-0097
Mailing Address - Fax:843-725-3118
Practice Address - Street 1:1470 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4707
Practice Address - Country:US
Practice Address - Phone:843-556-7060
Practice Address - Fax:843-556-9960
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2017-02-17
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Provider Licenses
StateLicense IDTaxonomies
SC019842208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC198427Medicaid
SC20 4068094OtherTAX ID
SC8519Medicare PIN
SCH302678519Medicare UPIN