Provider Demographics
NPI:1538190012
Name:THOMAS, MARK E (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:THOMAS
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 1:9390 THE LANDING DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7120
Mailing Address - Country:US
Mailing Address - Phone:770-947-1112
Mailing Address - Fax:
Practice Address - Street 1:9390 THE LANDING DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7120
Practice Address - Country:US
Practice Address - Phone:770-947-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57599207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA529328395BMedicaid
GAP00333870OtherRAILROAD MEDICARE
GA529328395AMedicaid
GAI59754Medicare UPIN
GA08CBBVRMedicare PIN