1972687309 NPI number — DEBORAH WEN-YEE MARK MD

Table of content: DEBORAH WEN-YEE MARK MD (NPI 1972687309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972687309 NPI number — DEBORAH WEN-YEE MARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARK
Provider First Name:
DEBORAH
Provider Middle Name:
WEN-YEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1972687309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 25TH AVENUE NORTH
Provider Second Line Business Mailing Address:
CENTENNIAL PEDIATRICS PC SUITE 201
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-620-5154
Provider Business Mailing Address Fax Number:
615-321-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 WINWOOD DRIVE
Provider Second Line Business Practice Location Address:
CENTENNIAL PEDIATRICS STE 105
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-453-1930
Provider Business Practice Location Address Fax Number:
615-453-1848
Provider Enumeration Date:
10/24/2006

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: 208000000X , with the licence number:  MA68658 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 42798 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1501011 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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