Provider Demographics
NPI:1104925536
Name:WATHEN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WATHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 W 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2488
Mailing Address - Country:US
Mailing Address - Phone:931-372-0405
Mailing Address - Fax:931-372-0463
Practice Address - Street 1:228 W 4TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2488
Practice Address - Country:US
Practice Address - Phone:931-372-0405
Practice Address - Fax:931-372-0463
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23921207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4288686OtherBCBS
TN1509597Medicaid
TN4288686OtherBCBS
F37417Medicare UPIN