Provider Demographics
NPI:1750380689
Name:STOVROFF, MARK COOPER (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:COOPER
Last Name:STOVROFF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:755 MOUNT VERNON HWY NE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4274
Mailing Address - Country:US
Mailing Address - Phone:404-252-7900
Mailing Address - Fax:404-252-7905
Practice Address - Street 1:755 MOUNT VERNON HWY NE
Practice Address - Street 2:SUITE 460
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-252-7900
Practice Address - Fax:404-252-7905
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2012-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0370882086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00552736DMedicaid
GA00552736DMedicaid