Healthcare Provider Details

I. General information

NPI: 1689664674
Provider Name (Legal Business Name): MARK ALAN BRANCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 09/08/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E 4TH AVE
CORDELE GA
31015
US

IV. Provider business mailing address

412 E 4TH AVE
CORDELE GA
31015
US

V. Phone/Fax

Practice location:
  • Phone: 229-273-1243
  • Fax: 229-273-1247
Mailing address:
  • Phone: 229-273-1243
  • Fax: 229-273-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number81934
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: