Provider Demographics
NPI:1326494568
Name:WHEELER, MARK LYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LYLE
Last Name:WHEELER
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2G
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3497
Practice Address - Fax:321-768-5082
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022241207R00000X
FLOS18501207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH033OtherHF MA
FL114293700Medicaid