Provider Demographics
NPI:1518002559
Name:KERESTON, MARK ANTHONY (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:KERESTON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 NW 36TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-8139
Mailing Address - Country:US
Mailing Address - Phone:352-373-6165
Mailing Address - Fax:
Practice Address - Street 1:1135 NW 23RD AVE
Practice Address - Street 2:SUITE F
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5415
Practice Address - Country:US
Practice Address - Phone:352-376-8410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 0017566225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist