Provider Demographics
NPI:1548212863
Name:PHILLIPS, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3627 WEBBER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-4412
Mailing Address - Country:US
Mailing Address - Phone:941-955-6773
Mailing Address - Fax:941-365-8627
Practice Address - Street 1:3627 WEBBER ST
Practice Address - Street 2:SUITE A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-4412
Practice Address - Country:US
Practice Address - Phone:941-955-6773
Practice Address - Fax:941-365-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2012-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0054689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10486Medicare ID - Type Unspecified