Provider Demographics
NPI:1184694630
Name:DODD, MARK ALAN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:DODD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-719-6100
Mailing Address - Fax:336-719-2313
Practice Address - Street 1:865 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-719-6100
Practice Address - Fax:336-719-2313
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126U0Medicaid
VA1184694630Medicaid
NC2401143Medicare ID - Type Unspecified
NC89126U0Medicaid