Provider Demographics
NPI:1720040488
Name:BARETTELLA, MARK BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BERNARD
Last Name:BARETTELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:STE 310
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-257-6644
Mailing Address - Fax:386-257-6557
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:STE 310
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-257-6644
Practice Address - Fax:386-257-6557
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061488207RI0011X
OH35061123B207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
41997YMedicare PIN
E92019Medicare UPIN