Provider Demographics
NPI:1972882355
Name:ROMANO, MARK ADRIAN (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ADRIAN
Last Name:ROMANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N JOHN YOUNG PKWY STE 203
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-6601
Mailing Address - Country:US
Mailing Address - Phone:407-624-3062
Mailing Address - Fax:407-613-2223
Practice Address - Street 1:200 N JOHN YOUNG PKWY STE 203
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-624-3062
Practice Address - Fax:407-613-2223
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010891208600000X
FLOS 13080208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014705800Medicaid
FL14Z95OtherFLORIDA BLUE
FL014705800Medicaid