Provider Demographics
NPI:1588824825
Name:FERRARA, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:FERRARA
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 1746
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1746
Mailing Address - Country:US
Mailing Address - Phone:877-383-4442
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063961A2085R0202X
GA0631912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00963909OtherRR MEDICARE
IN200905210Medicaid
INP00629941OtherRAILROAD MEDICARE
GA899100669Medicaid
IN340950KMedicare PIN
INP00629941OtherRAILROAD MEDICARE
IN611890IMedicare PIN