Provider Demographics
NPI:1619089125
Name:MARK, EDWARD K JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:K
Last Name:MARK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4274 N VALDOSTA RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6814
Mailing Address - Country:US
Mailing Address - Phone:229-242-1234
Mailing Address - Fax:229-247-8110
Practice Address - Street 1:4274 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6814
Practice Address - Country:US
Practice Address - Phone:229-242-1234
Practice Address - Fax:229-247-8110
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA029908207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00370686DMedicaid
D40544Medicare UPIN
GA00370686DMedicaid