Provider Demographics
NPI:1811008568
Name:MARK, BRUCE (DC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 POLK ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4822
Mailing Address - Country:US
Mailing Address - Phone:954-925-7333
Mailing Address - Fax:954-925-7339
Practice Address - Street 1:2607 POLK ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020
Practice Address - Country:US
Practice Address - Phone:954-925-7333
Practice Address - Fax:954-925-7339
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10266111N00000X
FLCH7442111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55652Medicare ID - Type Unspecified
FL74152Medicare UPIN
FL74152Medicare UPIN