Provider Demographics
NPI:1265439624
Name:CRIDER, MARK SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SAMUEL
Last Name:CRIDER
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 1:400 CELEBRATION PL
Mailing Address - Street 2:SUITE A-310
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4970
Mailing Address - Country:US
Mailing Address - Phone:407-566-2229
Mailing Address - Fax:407-566-2499
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:SUITE A-310
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-566-2229
Practice Address - Fax:407-566-2499
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90456174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270223100Medicaid
FLI15350Medicare UPIN
FL270223100Medicaid