Healthcare Provider Details

I. General information

NPI: 1891795498
Provider Name (Legal Business Name): MARK J. WHALEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 COURT DR
GASTONIA NC
28054-2140
US

IV. Provider business mailing address

4007 WILD NURSERY CT
CHARLOTTE NC
28215-5345
US

V. Phone/Fax

Practice location:
  • Phone: 704-834-2851
  • Fax: 704-834-2815
Mailing address:
  • Phone: 704-616-7387
  • Fax: 704-834-2815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number95-01148
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: