Provider Demographics
NPI:1093752719
Name:EL-DEIRY, MARK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:EL-DEIRY
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 1:775 POPLAR RD STE 240
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8300
Mailing Address - Country:US
Mailing Address - Phone:770-400-7830
Mailing Address - Fax:
Practice Address - Street 1:775 POPLAR RD STE 240
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8300
Practice Address - Country:US
Practice Address - Phone:770-400-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 98348207Y00000X
GA66483207YX0007X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96608OtherBLUE CROSS BLUE SHIELD
FL278414900Medicaid
I52949Medicare UPIN
FL278414900Medicaid