Provider Demographics
NPI:1104857697
Name:BOYTIM, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:BOYTIM
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 1:701 SAVANNAH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1550
Mailing Address - Country:US
Mailing Address - Phone:302-645-2805
Mailing Address - Fax:302-645-1164
Practice Address - Street 1:701 SAVANNAH RD
Practice Address - Street 2:SUITE B
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1550
Practice Address - Country:US
Practice Address - Phone:302-645-2805
Practice Address - Fax:302-645-1164
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000089201Medicaid
DEP00233933Medicare ID - Type UnspecifiedRAILROAD MEDICARE
DE0000089201Medicaid
DEE21844Medicare UPIN