Basic Information
| Provider Information | |||||||||
| NPI: | 1104872019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILITANA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232203709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043703082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 804 SOUTH ADAMS STREET | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048625680 | ||||||||
| FaxNumber: | 8048625698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101045615 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 2014-02252 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.