Provider Demographics
NPI:1104899764
Name:HALL, MARK E (DPM PA)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:HALL
Suffix:
Gender:M
Credentials:DPM PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7556 LAKE WORTH RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2503
Mailing Address - Country:US
Mailing Address - Phone:561-966-5060
Mailing Address - Fax:561-966-4489
Practice Address - Street 1:7556 LAKE WORTH RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2503
Practice Address - Country:US
Practice Address - Phone:561-966-5060
Practice Address - Fax:561-966-4489
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02108213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057613100Medicaid
FL65220OtherBC/BS OF FL
FL65-0960025OtherTAX ID #
FLP02108OtherFLORIDA LICENSE #
FL057613100Medicaid
FL65220Medicare ID - Type Unspecified