Provider Demographics
NPI:1386645554
Name:EDWARDS, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:EDWARDS
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 1:4713 HIGHWAY 90
Mailing Address - Street 2:AFC UC
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1403
Mailing Address - Country:US
Mailing Address - Phone:850-304-0694
Mailing Address - Fax:850-304-0707
Practice Address - Street 1:4713 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1403
Practice Address - Country:US
Practice Address - Phone:850-304-0694
Practice Address - Fax:850-304-0707
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116022207P00000X, 2083A0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine