Provider Demographics
NPI:1184620692
Name:NANNI, MARK DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:NANNI
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 1:122 LINSLEY AVE
Mailing Address - Street 2:STE A
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5121
Mailing Address - Country:US
Mailing Address - Phone:813-657-4914
Mailing Address - Fax:813-657-4916
Practice Address - Street 1:613 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5714
Practice Address - Country:US
Practice Address - Phone:813-661-2222
Practice Address - Fax:813-681-8494
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME455562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60973Medicare UPIN
FL03819Medicare ID - Type Unspecified