Provider Demographics
NPI:1881665917
Name:KANAREK, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KANAREK
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:PO BOX 2715
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-2715
Mailing Address - Country:US
Mailing Address - Phone:813-655-0292
Mailing Address - Fax:813-655-4302
Practice Address - Street 1:621 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4313
Practice Address - Country:US
Practice Address - Phone:813-655-0292
Practice Address - Fax:813-655-4302
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81188208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics