Provider Demographics
NPI:1457460396
Name:WARREN, MARK G (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:WARREN
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 1:821 S.W. 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435
Mailing Address - Country:US
Mailing Address - Phone:561-369-3300
Mailing Address - Fax:561-734-2811
Practice Address - Street 1:1325 S CONGRESS AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-5876
Practice Address - Country:US
Practice Address - Phone:561-369-3300
Practice Address - Fax:561-734-2811
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1194213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04125710-0Medicaid
T-55572Medicare UPIN
FL04125710-0Medicaid
4476330001Medicare NSC