Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 9401496 | NC |
NPI | 1003801655 |
---|---|
Provider Name | Dr. Mark O Speight |
First Address | Matthews, NC 28105-5547 |
Second Address | Matthews, NC 28105-5547 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2005 |
Last Update Date | 02/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D17678 | (02) |