Basic Information
| Provider Information | |||||||||
| NPI: | 1508917147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAULDIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3109 BIENVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395644361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288181111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
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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 | MS14371 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00115752 | 05 | MS | MEDICAID | 646000515 | 01 | BLUE CROSS OF MS | OTHER | 646000515 | 01 | TRICARE | OTHER | 009926495 | 05 | AL | MEDICAID | 930027001 | 01 | MEDICARE RAILROAD | OTHER |