Provider Demographics
NPI:1568567766
Name:SCHELLHAMMER, MARK DONALD (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DONALD
Last Name:SCHELLHAMMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 BOREN DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-2989
Mailing Address - Country:US
Mailing Address - Phone:407-292-2156
Mailing Address - Fax:407-241-2868
Practice Address - Street 1:1555 BOREN DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-2989
Practice Address - Country:US
Practice Address - Phone:407-292-2156
Practice Address - Fax:407-241-2868
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006516174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378178000Medicaid
FL57273OtherBCBS - FL
2079783OtherAETNA PPO
FL57273YMedicare PIN
2079783OtherAETNA PPO