Provider Demographics
NPI:1891761128
Name:COCKBURN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COCKBURN
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 1:11760 BIRD RD
Mailing Address - Street 2:SUITE 722
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3582
Mailing Address - Country:US
Mailing Address - Phone:305-559-1883
Mailing Address - Fax:305-559-1887
Practice Address - Street 1:11760 BIRD RD
Practice Address - Street 2:SUITE 722
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3582
Practice Address - Country:US
Practice Address - Phone:305-559-1883
Practice Address - Fax:305-559-1887
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111035208600000X, 2086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006267200Medicaid
NJG57875Medicare UPIN
NJ064831Q67Medicare ID - Type Unspecified
FLFZ458ZMedicare PIN