Provider Demographics
NPI:1790756138
Name:CHASTAIN, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:CHASTAIN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:835 COGBURN AVE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1031
Mailing Address - Country:US
Mailing Address - Phone:770-422-5557
Mailing Address - Fax:770-422-5456
Practice Address - Street 1:835 COGBURN AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1031
Practice Address - Country:US
Practice Address - Phone:770-422-5557
Practice Address - Fax:770-422-5456
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2020-06-12
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Provider Licenses
StateLicense IDTaxonomies
GA048995207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA339883816AMedicaid
GAP00086676OtherRAILROAD MEDICARE
GA339883816AMedicaid
GAP00086676OtherRAILROAD MEDICARE