Provider Demographics
NPI:1710940325
Name:BIRD, MARK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:BIRD
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 1:159 EXECUTIVE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4160
Mailing Address - Country:US
Mailing Address - Phone:434-792-5964
Mailing Address - Fax:434-792-5971
Practice Address - Street 1:159 EXECUTIVE DR
Practice Address - Street 2:SUITE C
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4160
Practice Address - Country:US
Practice Address - Phone:434-792-5964
Practice Address - Fax:434-792-5971
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010123776208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010151163Medicaid
VAP00223399OtherRAILROAD MEDICARE
VA177390OtherANTHEM
VA007298570Medicare ID - Type Unspecified
VAP00223399OtherRAILROAD MEDICARE