Provider Demographics
NPI:1134528821
Name:HAGWOOD, MARK TYNER (DPC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:TYNER
Last Name:HAGWOOD
Suffix:
Gender:M
Credentials:DPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7423
Mailing Address - Country:US
Mailing Address - Phone:601-863-8430
Mailing Address - Fax:
Practice Address - Street 1:128 MAPLE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-863-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1924101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional