Provider Demographics
NPI:1932128337
Name:CARTER, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:CARTER
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 1:4521 SHILOH MILL BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246
Mailing Address - Country:US
Mailing Address - Phone:904-699-4337
Mailing Address - Fax:
Practice Address - Street 1:4521 SHILOH MILL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-1880
Practice Address - Country:US
Practice Address - Phone:904-699-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4210302085R0202X
FLME477192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061625700Medicaid
FL14189XMedicare PIN
FL14189XMedicare UPIN
FL14189YMedicare UPIN
PAD61756Medicare UPIN
PA072800KAOMedicare ID - Type Unspecified