Provider Demographics
NPI:1760115125
Name:MARKS, DOUGLAS MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:MARKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E MONTGOMERY AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-3322
Mailing Address - Country:US
Mailing Address - Phone:812-455-9192
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:812-455-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical