Provider Demographics
NPI:1912958794
Name:STALLWORTH, MARK JUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JUNG
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 TRENWEST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3208
Mailing Address - Country:US
Mailing Address - Phone:336-970-5300
Mailing Address - Fax:336-970-5298
Practice Address - Street 1:1900 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3913
Practice Address - Country:US
Practice Address - Phone:336-970-5300
Practice Address - Fax:336-659-2379
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94010552085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8979159Medicaid
NC8979159Medicaid
NC2201366MMedicare PIN
NC2201366NMedicare PIN
NC2201366BMedicare ID - Type Unspecified
NC2201366PMedicare PIN