Basic Information
| Provider Information | |||||||||
| NPI: | 1538157359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COGGINS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245516 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 FRANKLIN RD SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405106200 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 0101251922 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 0101251922 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1538157359 | 05 | VA | MEDICAID |