Provider Demographics
NPI:1134121338
Name:HANABURY, MARK R JR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HANABURY
Suffix:JR
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 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3433
Mailing Address - Fax:540-772-5994
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3433
Practice Address - Fax:540-772-5994
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031266174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4243474OtherAETNA
TN0101OtherJOHN DEERE
143175OtherANTHEM
VA1134121338Medicaid
VA010083621Medicaid
1000135OtherUNITED HEALTH
243144OtherSOUTHERN HEALTH
VAB07330Medicare UPIN
VAP00143294Medicare ID - Type UnspecifiedRAILROAD MEDICARE
021426L84Medicare PIN
143175OtherANTHEM
VA010083621Medicaid