1669409215 NPI number — MR. MARK TIMOTHY SIZEMORE IDC

Table of content: MR. MARK TIMOTHY SIZEMORE IDC (NPI 1669409215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669409215 NPI number — MR. MARK TIMOTHY SIZEMORE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIZEMORE
Provider First Name:
MARK
Provider Middle Name:
TIMOTHY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669409215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
132 LAKE WELLINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSLAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31548-5702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-576-8902
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL BRANCH HEALTH CLINIC
Provider Second Line Business Practice Location Address:
881 USS JAMES MADISON RD.
Provider Business Practice Location Address City Name:
KINGS BAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31547-2531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-573-2618
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)