Provider Demographics
NPI:1518087907
Name:DURDEN, MARK DANIEL IV (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
Last Name:DURDEN
Suffix:IV
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 1:1095 GRAY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1856
Mailing Address - Country:US
Mailing Address - Phone:478-745-6119
Mailing Address - Fax:478-745-6110
Practice Address - Street 1:1095 GRAY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1856
Practice Address - Country:US
Practice Address - Phone:478-745-6119
Practice Address - Fax:478-745-6110
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26-3813824OtherTAX ID NUMBER
GAG57962Medicare UPIN
GA11BDMWKMedicare PIN