Provider Demographics
NPI:1184603508
Name:VATAVUK, MARK K (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:VATAVUK
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 1:311 W 24TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2666
Mailing Address - Country:US
Mailing Address - Phone:814-454-4484
Mailing Address - Fax:814-452-7005
Practice Address - Street 1:311 W 24TH ST STE 305
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2666
Practice Address - Country:US
Practice Address - Phone:814-454-4484
Practice Address - Fax:814-452-7005
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021568E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000712108Medicaid
PA000712108Medicaid
E63637Medicare UPIN