Provider Demographics
NPI:1881633402
Name:CASEBOLT, MARK ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:CASEBOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 SW 1ST AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-622-8152
Mailing Address - Fax:352-622-4408
Practice Address - Street 1:1541 SW 1ST AVE STE 105
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6506
Practice Address - Country:US
Practice Address - Phone:352-622-8152
Practice Address - Fax:352-622-4408
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109242208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003506600Medicaid
FLMB090OtherMEDICARE - FL
FLME109242OtherSTATE LICENSE
FL14C2EOtherBCBS OF FLORIDA