Provider Demographics
NPI:1992902266
Name:FORDHAM, MARK (CP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FORDHAM
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 RUIN CREEK RD
Mailing Address - Street 2:STE. 102
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2878
Mailing Address - Country:US
Mailing Address - Phone:252-436-2611
Mailing Address - Fax:
Practice Address - Street 1:451 RUIN CREEK RD
Practice Address - Street 2:STE. 102
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2878
Practice Address - Country:US
Practice Address - Phone:252-436-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795152Medicaid