Provider Demographics
NPI:1639376387
Name:SHERIDAN, MARK THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:SHERIDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 BUFORD HWY NE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1230
Mailing Address - Country:US
Mailing Address - Phone:770-451-9494
Mailing Address - Fax:
Practice Address - Street 1:5725 BUFORD HWY NE
Practice Address - Street 2:SUITE 105
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1230
Practice Address - Country:US
Practice Address - Phone:770-451-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 3071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP199Medicare ID - Type Unspecified
GA35ZCBPQMedicare UPIN