Provider Demographics
NPI:1578031860
Name:MARTIN, MARK (CCP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3846 SW 105TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9554
Mailing Address - Country:US
Mailing Address - Phone:352-215-4550
Mailing Address - Fax:
Practice Address - Street 1:6500 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4309
Practice Address - Country:US
Practice Address - Phone:352-333-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty