Provider Demographics
NPI:1033168539
Name:STAWARA, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:STAWARA
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 1:2035 PROFESSIONAL CTR DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4462
Mailing Address - Country:US
Mailing Address - Phone:904-272-0384
Mailing Address - Fax:904-272-6748
Practice Address - Street 1:2035 PROFESSIONAL CTR DR
Practice Address - Street 2:SUITE C
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4462
Practice Address - Country:US
Practice Address - Phone:904-272-0384
Practice Address - Fax:904-272-6748
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068585200Medicaid
FL068585200Medicaid
D52066Medicare UPIN