Provider Demographics
NPI:1821331273
Name:ERNEST, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:ERNEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 COQUINA WAY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-2747
Mailing Address - Country:US
Mailing Address - Phone:406-300-2025
Mailing Address - Fax:
Practice Address - Street 1:5 VIA DE LUNA DR UNIT I
Practice Address - Street 2:
Practice Address - City:PENSACOLA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32561-6809
Practice Address - Country:US
Practice Address - Phone:448-216-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.36816208D00000X, 207Q00000X
MT50575208D00000X, 207Q00000X
TN53134208D00000X
FLME164216208D00000X
VA0101258254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty