Provider Demographics
NPI:1265516892
Name:COKER, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14557 HIGHWAY 19 STE A
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-9582
Mailing Address - Country:US
Mailing Address - Phone:678-688-1580
Mailing Address - Fax:678-688-1594
Practice Address - Street 1:14557 HIGHWAY 19 STE A
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-9582
Practice Address - Country:US
Practice Address - Phone:678-688-1580
Practice Address - Fax:678-688-1594
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA056276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA579118048JMedicaid