Provider Demographics
NPI:1265431092
Name:ELLISON, MARK FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDERICK
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 6127
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-6127
Mailing Address - Country:US
Mailing Address - Phone:706-612-9401
Mailing Address - Fax:706-612-9410
Practice Address - Street 1:2142 W BROAD ST
Practice Address - Street 2:BUILDING 200, SUITE 200
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3506
Practice Address - Country:US
Practice Address - Phone:706-612-9401
Practice Address - Fax:706-612-9410
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA026107208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000370994FMedicaid
GA000370994FMedicaid
GABE1329184OtherDEA
GA34BDBKVMedicare ID - Type Unspecified