Provider Demographics
NPI:1376506048
Name:CASANTA, MARK R (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:CASANTA
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 1:1120 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2229
Mailing Address - Country:US
Mailing Address - Phone:727-641-5570
Mailing Address - Fax:
Practice Address - Street 1:2323 9TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6832
Practice Address - Country:US
Practice Address - Phone:727-323-1111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73964207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG66872Medicare UPIN