Provider Demographics
NPI:1811171259
Name:WIGHTMAN, MARK W
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 HWY 76 W
Mailing Address - Street 2:SUITE D
Mailing Address - City:HIAWASSEE
Mailing Address - State:GA
Mailing Address - Zip Code:30546-2146
Mailing Address - Country:US
Mailing Address - Phone:706-896-2872
Mailing Address - Fax:706-896-2873
Practice Address - Street 1:1460 HWY 76 W
Practice Address - Street 2:SUITE D
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-2146
Practice Address - Country:US
Practice Address - Phone:706-896-2872
Practice Address - Fax:706-896-2873
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies