Provider Demographics
NPI:1063487676
Name:HANLEY, MARK RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:HANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-254-7717
Mailing Address - Fax:321-428-4526
Practice Address - Street 1:1305 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3127
Practice Address - Country:US
Practice Address - Phone:321-254-7717
Practice Address - Fax:321-428-4526
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME86470208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267063100Medicaid
FLP00242439OtherRR MEDICARE
FLP00242439OtherRR MEDICARE
FLH77279Medicare UPIN