Provider Demographics
NPI:1447232400
Name:WILLINGHAM, MARK CAUTHEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CAUTHEN
Last Name:WILLINGHAM
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-7595
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-7595
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701197207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6605231Medicaid
WV2003688000Medicaid
1069EOtherBCBS
220032284OtherRR MEDICARE
36474OtherPARTNERS
7364331OtherAETNA
NC891069EMedicaid
74320OtherMEDCOST
SCQ01199Medicaid
2279938AOtherMEDICARE
SCQ01199Medicaid
WV2003688000Medicaid