Provider Demographics
NPI:1538499884
Name:MARK, TERESA ROSE-MARIE
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:ROSE-MARIE
Last Name:MARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:410-494-1379
Mailing Address - Fax:410-494-2737
Practice Address - Street 1:849 FAIRMONT AVENUE
Practice Address - Street 2:SUITE 100A
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-2600
Practice Address - Country:US
Practice Address - Phone:410-494-1369
Practice Address - Fax:410-494-2737
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-09
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0077561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics