Provider Demographics
NPI:1134135122
Name:FANNIN, JOHN MARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:FANNIN
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 1:4600 NORTH DAVIS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503
Mailing Address - Country:US
Mailing Address - Phone:850-477-9073
Mailing Address - Fax:850-494-0065
Practice Address - Street 1:4600 N DAVIS HIGHWAY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-477-9073
Practice Address - Fax:850-494-0065
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96388207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL591-89048OtherBLUE CROSS BLUE SHIELD
FL276437700Medicaid
FL56071OtherBLUE CROSS BLUE SHIELD
AL009939839Medicaid
AL591-89048OtherBLUE CROSS BLUE SHIELD
I69524Medicare UPIN