Provider Demographics
NPI:1538119151
Name:DERSCH, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:DERSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-205-8981
Mailing Address - Fax:352-391-6498
Practice Address - Street 1:1901 SE 18TH AVE
Practice Address - Street 2:BLDG 300
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8215
Practice Address - Country:US
Practice Address - Phone:352-351-1313
Practice Address - Fax:352-351-1927
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME66575208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379266800Medicaid
FL25404OtherBCBS
FL4702200001Medicare NSC
FL25404YMedicare PIN
FLF83692Medicare UPIN
FL6219110002Medicare NSC