Provider Demographics
NPI:1750907143
Name:WANTAJA, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WANTAJA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CLINTON AVE E
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2924
Mailing Address - Country:US
Mailing Address - Phone:360-355-4215
Mailing Address - Fax:
Practice Address - Street 1:96 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1625
Practice Address - Country:US
Practice Address - Phone:276-679-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61432898207R00000X
VA0116034298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine