Provider Demographics
NPI:1962493361
Name:BECHTEL, MARK ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:BECHTEL
Suffix:
Gender:M
Credentials:DO
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 531797
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-1797
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:1680 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-2008
Practice Address - Country:US
Practice Address - Phone:843-524-3344
Practice Address - Fax:844-295-9894
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL996207Q00000X
NC2006-00859207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962493361Medicaid
SC009966Medicaid
SCP00349261OtherRAILROAD MEDICARE
NC5904471Medicaid
SCI08691Medicare UPIN
SCI086916221Medicare PIN