Provider Demographics
NPI:1851376891
Name:MARKS, MALCOLM WERNICK (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:WERNICK
Last Name:MARKS
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 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8759
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8759
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33087208200000X, 2082S0099X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
5671002OtherAETNA
NC38713OtherMEDCOST
NC2733OtherPARTNERS
VA6920080Medicaid
NC8953965Medicaid
WV200816000Medicaid
SCQ33087Medicaid
NC53965OtherBCBS
SCQ33087Medicaid
VA6920080Medicaid