Provider Demographics
NPI:1417303405
Name:WINTER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WINTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 GRANT CT
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-5117
Mailing Address - Country:US
Mailing Address - Phone:920-574-0143
Mailing Address - Fax:
Practice Address - Street 1:2700 UNIVERSITY SQUARE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5513
Practice Address - Country:US
Practice Address - Phone:813-253-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12215487-12052085R0202X
390200000X
FLME1650382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program