Provider Demographics
NPI:1184628844
Name:ANDERSON, MARK WENDELL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WENDELL
Last Name:ANDERSON
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 7200
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0200
Mailing Address - Country:US
Mailing Address - Phone:252-937-0200
Mailing Address - Fax:252-451-0056
Practice Address - Street 1:901 N WINSTEAD AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8467
Practice Address - Country:US
Practice Address - Phone:252-937-0231
Practice Address - Fax:252-937-3113
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400098207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136HGMedicaid
NC89136HGMedicaid
NC2024358Medicare PIN