Healthcare Provider Details

I. General information

NPI: 1366485179
Provider Name (Legal Business Name): JON MARK MACNAUGHTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J. MARK MACNAUGHTON M.D.

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 PARKSIDE DR STE 109
KNOXVILLE TN
37934-1980
US

IV. Provider business mailing address

208 GLEN MAR DR
LENOIR CITY TN
37772-3960
US

V. Phone/Fax

Practice location:
  • Phone: 865-218-6640
  • Fax:
Mailing address:
  • Phone: 865-986-4316
  • Fax: 865-567-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD023561
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number141319
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number23561
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: