Provider Demographics
NPI:1558349563
Name:FIRESTONE, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:FIRESTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21110 BISCAYNE BLVD
Mailing Address - Street 2:#312
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1227
Mailing Address - Country:US
Mailing Address - Phone:305-933-3030
Mailing Address - Fax:305-933-1436
Practice Address - Street 1:21110 BISCAYNE BLVD
Practice Address - Street 2:312
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1227
Practice Address - Country:US
Practice Address - Phone:305-933-3030
Practice Address - Fax:305-933-1436
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME47978207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0750NSHROtherNEIGHBORHOOD HEALTH
FL103541OtherAVMED
FL02883VMedicare ID - Type Unspecified
FLD20800Medicare UPIN