Provider Demographics
NPI:1346857257
Name:TABOR, MARK JAMES (DO/PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:TABOR
Suffix:
Gender:M
Credentials:DO/PHD
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 82
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:WV
Mailing Address - Zip Code:25625-0082
Mailing Address - Country:US
Mailing Address - Phone:304-792-0541
Mailing Address - Fax:
Practice Address - Street 1:418 COOLIDGE AVENUE #42
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:WV
Practice Address - Zip Code:25625-0082
Practice Address - Country:US
Practice Address - Phone:304-792-0541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty