Provider Demographics
NPI:1568154854
Name:OGLETREE, MARK EVAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EVAN
Last Name:OGLETREE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 SHILOH RD NW APT 810
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6465
Mailing Address - Country:US
Mailing Address - Phone:770-823-9638
Mailing Address - Fax:
Practice Address - Street 1:1615 RIDENOUR BLVD NW STE 204
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4464
Practice Address - Country:US
Practice Address - Phone:770-580-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist