Provider Demographics
NPI:1639153638
Name:LING, MARK RUSSELL (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RUSSELL
Last Name:LING
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:710 NEWNAN CROSSING BYPASS
Practice Address - Street 2:SUITE A
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2321
Practice Address - Country:US
Practice Address - Phone:770-251-5111
Practice Address - Fax:770-254-8680
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034647207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4279563008OtherCIGNA HMO
GA0390142OtherUHC
GA070012632OtherRAIL ROAD MEDICARE
GA2117569OtherAETNA HMO
GA00469246CMedicaid
GA4318069OtherAETNA NON-HMO
GA07BBSFGMedicare ID - Type Unspecified
GA2117569OtherAETNA HMO