Provider Demographics
NPI:1629165154
Name:DEDRICK, MARK EDWARD (AAS, BS, MSOM, AP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:DEDRICK
Suffix:
Gender:M
Credentials:AAS, BS, MSOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 DOCKSIDER DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-6329
Mailing Address - Country:US
Mailing Address - Phone:904-742-2967
Mailing Address - Fax:
Practice Address - Street 1:8280 PRINCETON SQUARE BLVD W STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0362
Practice Address - Country:US
Practice Address - Phone:904-742-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1427171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist