Provider Demographics
NPI:1861496648
Name:TEAGUE, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:2331 SEMINOLE LN
Practice Address - Street 2:STE 102
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8319
Practice Address - Country:US
Practice Address - Phone:434-244-0162
Practice Address - Fax:434-244-0153
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL18786207ZD0900X, 207ZP0102X
TN20922207ZP0102X
VA0101232830207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000028189Medicaid
AL051028189OtherBCBS
AL51028189Medicare PIN
AL000028189Medicaid