Provider Demographics
NPI:1265434211
Name:MCTAMMANY, MARK STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:MCTAMMANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3127
Mailing Address - Country:US
Mailing Address - Phone:321-344-7677
Mailing Address - Fax:321-344-7678
Practice Address - Street 1:1315 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3127
Practice Address - Country:US
Practice Address - Phone:321-768-7677
Practice Address - Fax:321-768-7756
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072191207VG0400X
FLME72191207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8653840OtherCIGNA
FL5510582OtherAETNA
FL252532100Medicaid
FL8653840OtherCIGNA
FL5510582OtherAETNA