Provider Demographics
NPI:1255409017
Name:VULETICH, MARK A (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:VULETICH
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 1:717 BOUNTY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8071
Mailing Address - Country:US
Mailing Address - Phone:843-814-2925
Mailing Address - Fax:
Practice Address - Street 1:1201 S SHANNON AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3439
Practice Address - Country:US
Practice Address - Phone:321-213-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8108207P00000X
SCTL1401207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC014013Medicaid
SCAA52385668Medicare PIN
FL35722AMedicare ID - Type Unspecified
SC014013Medicaid