Provider Demographics
NPI:1356339063
Name:BOOKOUT, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:BOOKOUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6918 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-6784
Mailing Address - Country:US
Mailing Address - Phone:423-855-2552
Mailing Address - Fax:423-855-9041
Practice Address - Street 1:4151 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2434
Practice Address - Country:US
Practice Address - Phone:423-622-5165
Practice Address - Fax:423-622-5167
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN011511207Y00000X
GA025947207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000282125BMedicaid
TN3021453Medicaid
A98527Medicare UPIN
TN3021453Medicaid