Provider Demographics
NPI:1982167789
Name:UNDERWOOD, MARCUS A (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:A
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 VININGS PKWY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3863
Mailing Address - Country:US
Mailing Address - Phone:678-523-1547
Mailing Address - Fax:
Practice Address - Street 1:123 VININGS PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3863
Practice Address - Country:US
Practice Address - Phone:678-523-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0023772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT002377OtherGEORGIA SECRETARY OF STATE
BOC217903OtherBOARD OF CERTIFICATION