Provider Demographics
NPI:1972592475
Name:BENAK, MARK ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:BENAK
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 1:729 HAMPTON
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2083
Mailing Address - Country:US
Mailing Address - Phone:770-266-0541
Mailing Address - Fax:
Practice Address - Street 1:4350 TOWNE CENTRE DR STE 2000
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3331
Practice Address - Country:US
Practice Address - Phone:706-854-3333
Practice Address - Fax:706-854-2179
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048976174400000X
GA48976208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00900611AMedicaid
GA02BDHTGMedicare ID - Type Unspecified
GAG43811Medicare UPIN