Healthcare Provider Details

I. General information

NPI: 1093752719
Provider Name (Legal Business Name): MARK WILLIAM EL-DEIRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POPLAR RD STE 240
NEWNAN GA
30265-8300
US

IV. Provider business mailing address

775 POPLAR RD STE 240
NEWNAN GA
30265-8300
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-7830
  • Fax:
Mailing address:
  • Phone: 770-400-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME 98348
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number66483
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number66483
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: