Provider Demographics
NPI:1619436136
Name:TIMES, MARK D
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:TIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 SE BREKENRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-8139
Mailing Address - Country:US
Mailing Address - Phone:772-212-6701
Mailing Address - Fax:
Practice Address - Street 1:2363 SE BREKENRIDGE CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-8139
Practice Address - Country:US
Practice Address - Phone:772-212-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care