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Individual

DR. MARK JUNG STALLWORTH

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
1900 S HAWTHORNE RD, WINSTON SALEM, NC 27103-3913
(336) 970-5300
(336) 659-2379
Mailing address
3010 TRENWEST DR, WINSTON SALEM, NC 27103-3208
(336) 970-5300
(336) 970-5298

Taxonomy

Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
9401055
NC
2085R0204X
Vascular & Interventional Radiology Physician
9401055
NC

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
8979159
NC
Enumeration date
05/15/2006
Last updated
09/14/2016
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