Provider Demographics
NPI:1780664086
Name:MEDLEY, MARK FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDERICK
Last Name:MEDLEY
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 1:1414 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7505
Mailing Address - Country:US
Mailing Address - Phone:910-763-7363
Mailing Address - Fax:910-251-8296
Practice Address - Street 1:1414 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7505
Practice Address - Country:US
Practice Address - Phone:910-763-7363
Practice Address - Fax:910-251-8296
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8958473Medicaid
NC8958473Medicaid
NC2219369Medicare ID - Type Unspecified