Healthcare Provider Details

I. General information

NPI: 1790724433
Provider Name (Legal Business Name): MARK FREDERICK STEGELMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 WAYNE AVE NE
ATLANTA GA
30306-3233
US

IV. Provider business mailing address

PO BOX 133091
ATLANTA GA
30333-3091
US

V. Phone/Fax

Practice location:
  • Phone: 404-881-6600
  • Fax: 404-881-1066
Mailing address:
  • Phone: 404-881-6600
  • Fax: 404-881-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number034721
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME89382
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18853
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27667
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: