Provider Demographics
NPI:1689863615
Name:MAHONEY, MARK T (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112
Mailing Address - Country:US
Mailing Address - Phone:276-666-0500
Mailing Address - Fax:276-666-0400
Practice Address - Street 1:100 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112
Practice Address - Country:US
Practice Address - Phone:276-666-0500
Practice Address - Fax:276-666-0400
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146677OtherANTHEM
VA00W138M01OtherMEDICARE
VA9960505OtherCIGNA
VA283562OtherSOUTHERN HEALTH
VA010098467Medicaid
VA7547584OtherAETNA
VAI22152Medicare UPIN