Provider Demographics
NPI:1225271018
Name:VANDEUSEN, MARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:VANDEUSEN
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 1:3195 POWERS FORD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067
Mailing Address - Country:US
Mailing Address - Phone:315-269-0291
Mailing Address - Fax:
Practice Address - Street 1:3180 N POINT PKWY STE 302
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4248
Practice Address - Country:US
Practice Address - Phone:678-679-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70919207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I047053Medicare PIN