Provider Demographics
NPI:1083623847
Name:KANTZLER, MARK G (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:KANTZLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33779-1619
Mailing Address - Country:US
Mailing Address - Phone:727-458-3011
Mailing Address - Fax:813-383-9924
Practice Address - Street 1:1155 S DALE MABRY HWY
Practice Address - Street 2:#19
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5035
Practice Address - Country:US
Practice Address - Phone:727-458-3011
Practice Address - Fax:813-383-9924
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 5165207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8834Medicare ID - Type UnspecifiedMEDICARE GROUP
82891Medicare ID - Type Unspecified
E32311Medicare UPIN