Provider Demographics
NPI:1164414769
Name:MESSENGER, MARK T (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:MESSENGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-7318
Mailing Address - Country:US
Mailing Address - Phone:706-597-0102
Mailing Address - Fax:706-597-1998
Practice Address - Street 1:1043 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7318
Practice Address - Country:US
Practice Address - Phone:706-597-0102
Practice Address - Fax:706-597-1998
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000713213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000701511EMedicaid
GAGRP433Medicaid
GAGRP4355OtherMEDICARE
GAGRP4355Medicare PIN
GAGRP4355OtherMEDICARE
GAGRP433Medicaid