Provider Demographics
NPI:1356307045
Name:NATHANSON, MARC A (DPM)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:NATHANSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8851 BOARDROOM CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FORT MEYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4888
Mailing Address - Country:US
Mailing Address - Phone:239-481-7000
Mailing Address - Fax:239-481-8150
Practice Address - Street 1:8851 BOARDROOM CIRCLE
Practice Address - Street 2:
Practice Address - City:FORT MEYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4888
Practice Address - Country:US
Practice Address - Phone:239-481-7000
Practice Address - Fax:239-481-8150
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2709213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4800029458OtherRAILROAD MEDICARE
FL1304850001OtherMEDICARE DME
FL4800029458OtherRAILROAD MEDICARE
FL1304850001OtherMEDICARE DME
FL65553YMedicare PIN
FL65553YMedicare PIN