Provider Demographics
NPI:1285667394
Name:PUGLISI, MARK F JR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:PUGLISI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W UNDERWOOD ST # MP80
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:888-912-3648
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:86 W UNDERWOOD ST # MP80
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:888-912-3648
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005021705207R00000X, 208000000X
FLME107800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0026737-00Medicaid
FL0026737-00Medicaid
MOI52132Medicare UPIN
MO36626019OtherBCBS
MO701E491Medicare ID - Type Unspecified
MO7699670OtherAETNA
FL0026737-00Medicaid
MO207521402Medicaid
KS200376610AMedicaid