Provider Demographics
NPI:1568446920
Name:ANDREWS, MARK DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:ANDREWS
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:1930 PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4817
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-760-5367
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26180207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11394OtherBCBS
5782567OtherAETNA
12189OtherPARTNERS
NC8911394Medicaid
VA5611962Medicaid
NC204485DMedicare ID - Type Unspecified