Provider Demographics
NPI:1336170299
Name:TALBERT, MARK SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SHANE
Last Name:TALBERT
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 1:3466 N HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5713
Mailing Address - Country:US
Mailing Address - Phone:321-434-1982
Mailing Address - Fax:321-727-0975
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-727-0975
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000035863208600000X
FLME101090208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32763OtherBCBS OF FLORIDA
FL000086800Medicaid
FL4314703OtherCIGNA PIN
FLAJ974YMedicare PIN