Provider Demographics
NPI:1013908920
Name:DILLON, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:DILLON
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-8423
Mailing Address - Fax:
Practice Address - Street 1:1421 MALABAR RD NE STE 201
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2559
Practice Address - Country:US
Practice Address - Phone:321-434-8423
Practice Address - Fax:321-434-8148
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63710207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373405600Medicaid
FL100013898OtherRR MEDICARE
FLMM198OtherMEDICARE
F64111Medicare UPIN