Provider Demographics
NPI:1225129083
Name:HERBST, MARK DAVID (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1238
Mailing Address - Country:US
Mailing Address - Phone:727-327-5006
Mailing Address - Fax:727-327-3077
Practice Address - Street 1:3900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1238
Practice Address - Country:US
Practice Address - Phone:727-327-5006
Practice Address - Fax:727-327-3077
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 605332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14280XMedicare ID - Type Unspecified