Provider Demographics
NPI:1538140512
Name:RESTER, MARK OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:OWEN
Last Name:RESTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 LAKELAND SQUARE EXT
Mailing Address - Street 2:STE. 900
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7620
Mailing Address - Country:US
Mailing Address - Phone:601-326-7632
Mailing Address - Fax:601-326-7635
Practice Address - Street 1:1000 LAKELAND SQUARE EXT
Practice Address - Street 2:STE. 900
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7620
Practice Address - Country:US
Practice Address - Phone:601-326-7632
Practice Address - Fax:601-326-7635
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS166232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121487Medicaid
MS260000563Medicare Oscar/Certification
MS260000561Medicare ID - Type Unspecified
MS00121487Medicaid