Provider Demographics
NPI:1689637480
Name:LITTLE, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LITTLE
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 1:79 GIBBES ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1806
Mailing Address - Country:US
Mailing Address - Phone:843-937-9412
Mailing Address - Fax:843-937-9412
Practice Address - Street 1:2605 KINARD ST STE 200
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2965
Practice Address - Country:US
Practice Address - Phone:803-405-1900
Practice Address - Fax:803-405-1919
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571088212OtherCOMMERCIAL
SCAA05398028Medicare ID - Type Unspecified
SCI11886Medicare UPIN