Provider Demographics
NPI:1356341762
Name:VLASAK, MARK CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:VLASAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
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Mailing Address - Street 1:739 POLO RUN DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-7302
Mailing Address - Country:US
Mailing Address - Phone:901-854-4406
Mailing Address - Fax:
Practice Address - Street 1:1164 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3196
Practice Address - Country:US
Practice Address - Phone:901-853-5551
Practice Address - Fax:901-853-7303
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD17221207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3022998Medicare ID - Type Unspecified
TNA98690Medicare UPIN