Provider Demographics
NPI:1922447168
Name:DEAVER, MARK EUGENE
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EUGENE
Last Name:DEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-7262
Mailing Address - Country:US
Mailing Address - Phone:704-867-2474
Mailing Address - Fax:
Practice Address - Street 1:2500 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-7262
Practice Address - Country:US
Practice Address - Phone:704-867-2474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program