Provider Demographics
NPI:1508821588
Name:PSARAKIS, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:PSARAKIS
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 1:2222 S HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5594
Mailing Address - Country:US
Mailing Address - Phone:321-541-1777
Mailing Address - Fax:321-725-5504
Practice Address - Street 1:2222 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 430
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5594
Practice Address - Country:US
Practice Address - Phone:321-541-1777
Practice Address - Fax:321-725-5504
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378804100Medicaid
110101297OtherRAIL ROAD MEDICARE
FL378804100Medicaid
FL25114ZMedicare ID - Type Unspecified