Provider Demographics
NPI:1548373210
Name:TARK, MARVIN D (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:D
Last Name:TARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:400 TOWER RD NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9415
Mailing Address - Country:US
Mailing Address - Phone:770-590-1078
Mailing Address - Fax:770-422-7306
Practice Address - Street 1:400 TOWER ROAD
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9415
Practice Address - Country:US
Practice Address - Phone:770-590-1078
Practice Address - Fax:770-422-7306
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-04-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA018257208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000155339EMedicaid
GA000155339EMedicaid
GAD41210Medicare UPIN