Provider Demographics
NPI:1720157688
Name:PRIEST, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PRIEST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-8632
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:
Practice Address - Street 1:945 E 8TH ST STE B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2895
Practice Address - Country:US
Practice Address - Phone:231-922-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMP009980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE95678Medicare UPIN