Provider Demographics
NPI:1154649861
Name:BEDARD, MARK D (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BEDARD
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 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:2140 SMITH ST
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5554
Practice Address - Country:US
Practice Address - Phone:904-269-2140
Practice Address - Fax:904-264-3018
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS 12071208000000X
FLUO 2348208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008887400Medicaid