Provider Demographics
NPI:1770516163
Name:COUNTRYMAN, DAVID MARK (M D)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:COUNTRYMAN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5616
Mailing Address - Fax:828-650-8076
Practice Address - Street 1:109 BEE ST.
Practice Address - Street 2:DEPT OF SURGERY (112) CHARLESTON VA MEDICAL CENTER
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401
Practice Address - Country:US
Practice Address - Phone:228-239-7068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33352208600000X
MS9258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1555262OtherMEDICARE RAIL ROAD
NCNC7246BMedicare UPIN