Provider Demographics
NPI:1043325079
Name:MARCOS G JOPPERT MD
Entity Type:Organization
Organization Name:MARCOS G JOPPERT MD
Other - Org Name:FLORIDA CANCER SPECIALISTS COUNTRYSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-274-8200
Mailing Address - Street 1:3253 N MCMULLEN BOOTH RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3253 N MCMULLEN BOOTH RD
Practice Address - Street 2:STE 100
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2043
Practice Address - Country:US
Practice Address - Phone:727-725-8102
Practice Address - Fax:727-796-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73531332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265956500Medicaid
1013349OtherNCPDP PROVIDER IDENTIFICATION NUMBER