Provider Demographics
NPI:1124227459
Name:FUGATE, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:FUGATE
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 1:2501 CITICO AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1127
Mailing Address - Country:US
Mailing Address - Phone:423-697-2000
Mailing Address - Fax:423-697-2118
Practice Address - Street 1:2501 CITICO AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1127
Practice Address - Country:US
Practice Address - Phone:423-697-2000
Practice Address - Fax:423-697-2320
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD44206208600000X
TN442062086S0129X, 2086S0129X
MD219572086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00741318OtherRR MEDICARE
TN4230402OtherBCBS
TN1515384Medicaid
AL163534Medicaid
GA540820812AMedicaid
P00741318OtherRR MEDICARE