Provider Demographics
NPI:1629060512
Name:CALLENBERGER, MARK STEVEN (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:CALLENBERGER
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 1:333 W COCOA BEACH CSWY
Mailing Address - Street 2:STE E
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3513
Mailing Address - Country:US
Mailing Address - Phone:321-305-4931
Mailing Address - Fax:321-305-4933
Practice Address - Street 1:333 W COCOA BEACH CSWY
Practice Address - Street 2:STE E
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3513
Practice Address - Country:US
Practice Address - Phone:321-305-4931
Practice Address - Fax:321-305-4933
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8441207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268291500Medicaid
0178ZMedicare ID - Type Unspecified
FL268291500Medicaid
FL6192520001Medicare NSC