Provider Demographics
NPI:1437158979
Name:HOFSTETTER, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:HOFSTETTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1224 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6582
Mailing Address - Country:US
Mailing Address - Phone:706-922-0191
Mailing Address - Fax:706-922-0192
Practice Address - Street 1:1224 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6582
Practice Address - Country:US
Practice Address - Phone:706-922-0191
Practice Address - Fax:706-922-0192
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA067643207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGA1300Medicaid
GA003123605AMedicaid
GA52590314OtherBCBS OF GA
GA202I448744Medicare UPIN
GA202I119627Medicare UPIN
GA52590314OtherBCBS OF GA
PA0010268610002Medicaid