Provider Demographics
NPI:1316028335
Name:PEDEN, MARC C (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:C
Last Name:PEDEN
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 1:602 S MACDILL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4614
Mailing Address - Country:US
Mailing Address - Phone:813-875-6373
Mailing Address - Fax:813-876-0960
Practice Address - Street 1:602 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4614
Practice Address - Country:US
Practice Address - Phone:813-875-6373
Practice Address - Fax:813-876-0960
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN6699207W00000X
FLME96228207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278603600Medicaid
AE975ZMedicare PIN