Provider Demographics
NPI:1588007959
Name:KORMAN, MARK WRAY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WRAY
Last Name:KORMAN
Suffix:
Gender:M
Credentials:
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 67
Mailing Address - Street 2:107 H STREET EAST
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59201-0067
Mailing Address - Country:US
Mailing Address - Phone:406-768-3491
Mailing Address - Fax:406-768-5109
Practice Address - Street 1:107 H STREET EAST
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255-0067
Practice Address - Country:US
Practice Address - Phone:406-768-3491
Practice Address - Fax:406-768-5109
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV958246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9990118Medicaid
WVWV-958OtherLICENSE