Provider Demographics
NPI:1780668780
Name:WOLGIN, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:WOLGIN
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0407
Mailing Address - Country:US
Mailing Address - Phone:229-883-4707
Mailing Address - Fax:229-435-1038
Practice Address - Street 1:619 POINTE NORTH BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-1514
Practice Address - Country:US
Practice Address - Phone:229-883-4707
Practice Address - Fax:229-435-1038
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057862207X00000X, 207XS0117X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA525815749AMedicaid
GAF34718Medicare UPIN
GA20NCCNGMedicare PIN