Provider Demographics
NPI:1467441584
Name:GRIFFIS, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRIFFIS
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 1:111 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30428-9004
Mailing Address - Country:US
Mailing Address - Phone:912-523-5113
Mailing Address - Fax:912-523-2049
Practice Address - Street 1:111 NORTH 3RD ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30428-9004
Practice Address - Country:US
Practice Address - Phone:912-523-5113
Practice Address - Fax:912-523-2049
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00569676DMedicaid
GA08BBWNFMedicare ID - Type Unspecified
F68626Medicare UPIN