Provider Demographics
NPI:1073592606
Name:GILLESPY, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:GILLESPY
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 1:1075 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4611
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-258-3561
Practice Address - Street 1:1075 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4611
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-258-3561
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52207207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007651900Medicaid
FL370310000Medicaid
FLF29861Medicare UPIN
FL15189Medicare ID - Type Unspecified
FL0340420001Medicare NSC
FL15189ZMedicare PIN