Provider Demographics
NPI:1275536831
Name:PATTERSON, MARK KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KENNETH
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:ANTHONY KENNETH
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4040 POSTAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6438
Practice Address - Country:US
Practice Address - Phone:540-772-4453
Practice Address - Fax:540-722-4717
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010201004Medicaid
VA010205981Medicaid
VA6716458Medicaid
VA010205981Medicaid
VA6716458Medicaid
008912C95Medicare PIN