Healthcare Provider Details

I. General information

NPI: 1114919321
Provider Name (Legal Business Name): MARK ALBERT PASHAYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 LEWISVILLE CLEMMONS RD
CLEMMONS NC
27012-8905
US

IV. Provider business mailing address

PO BOX 602658
CHARLOTTE NC
28260-2658
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-0582
  • Fax: 336-713-0581
Mailing address:
  • Phone: 336-716-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95-01046
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8965775
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: