Provider Demographics
NPI:1609877752
Name:LAMIELLE, MARK EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:LAMIELLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10051 5TH STREET NORTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2211
Mailing Address - Country:US
Mailing Address - Phone:727-828-2370
Mailing Address - Fax:727-568-6011
Practice Address - Street 1:787 CORTARO DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-6812
Practice Address - Country:US
Practice Address - Phone:813-634-2500
Practice Address - Fax:813-634-3008
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4531207Q00000X
FLOS12113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0701280Medicaid
FL010843100Medicaid
OHLA0613532Medicare PIN
FL010843100Medicaid
FLHT183ZMedicare PIN