Provider Demographics
NPI:1326089574
Name:GUERDAN, MARK CARROLL (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CARROLL
Last Name:GUERDAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6525 PROFESSIONAL PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2519
Mailing Address - Country:US
Mailing Address - Phone:404-254-5496
Mailing Address - Fax:404-254-5829
Practice Address - Street 1:6525 PROFESSIONAL PL
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:404-254-5496
Practice Address - Fax:404-254-5829
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY31403163W00000X
NY62257207L00000X
GA061081207LP2900X, 208VP0014X
GA61081207L00000X, 208VP0000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No163W00000XNursing Service ProvidersRegistered Nurse
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135346AMedicaid
GA003135345AMedicaid
GA003135346AMedicaid