Provider Demographics
NPI:1386646800
Name:DAVIS, MARK JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COCONUT DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2607
Mailing Address - Country:US
Mailing Address - Phone:321-610-8939
Mailing Address - Fax:321-622-8728
Practice Address - Street 1:141 COCONUT DR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2607
Practice Address - Country:US
Practice Address - Phone:321-610-8939
Practice Address - Fax:321-622-8728
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065723207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250063900Medicaid
FL1281430001Medicare NSC
FLF97981Medicare UPIN
FL250063900Medicaid