Provider Demographics
NPI:1033172630
Name:MAEDERER, MARK A JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MAEDERER
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3095 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-4241
Mailing Address - Country:US
Mailing Address - Phone:305-642-4044
Mailing Address - Fax:305-642-2320
Practice Address - Street 1:3095 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125
Practice Address - Country:US
Practice Address - Phone:305-642-4044
Practice Address - Fax:305-642-2320
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2975213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65739YOtherMEDICARE LEGACY
FL3406512 00Medicaid
FL65739YOtherMEDICARE LEGACY