Provider Demographics
NPI:1336141555
Name:VANNORSDALL, MARK DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DEAN
Last Name:VANNORSDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11037
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1037
Mailing Address - Country:US
Mailing Address - Phone:850-444-7000
Mailing Address - Fax:850-444-7497
Practice Address - Street 1:1619 CREIGHTON RD STE 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504
Practice Address - Country:US
Practice Address - Phone:850-444-4700
Practice Address - Fax:850-444-7497
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14683207RN0300X
FLME137397207RN0300X
ALMD.23695207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100975100Medicaid
2282831Medicare ID - Type Unspecified
G68058Medicare UPIN
NC8912K0Medicaid