Healthcare Provider Details

I. General information

NPI: 1295785475
Provider Name (Legal Business Name): CORBETT MARK THIGPEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

IV. Provider business mailing address

3650 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9797
  • Fax: 706-868-9209
Mailing address:
  • Phone: 706-863-9797
  • Fax: 706-868-9209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number021058
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: