Provider Demographics
NPI:1033708052
Name:HAVLICEK, MARK GERARD (APN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GERARD
Last Name:HAVLICEK
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SKYTOP RDG
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-2355
Mailing Address - Country:US
Mailing Address - Phone:201-663-1988
Mailing Address - Fax:
Practice Address - Street 1:43 YAWPO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-2714
Practice Address - Country:US
Practice Address - Phone:201-337-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01014700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner