Basic Information
| Provider Information | |||||||||
| NPI: | 1679679310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAYLORD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 ALCOA HWY | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655446650 | ||||||||
| FaxNumber: | 8655446572 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 ALCOA HWY | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655446650 | ||||||||
| FaxNumber: | 8655446572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11704 | TN | Y | Other Service Providers | Specialist |
No ID Information.