Provider Demographics
NPI:1396729810
Name:PRESTON, MARK PAUL (MD, JD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:PRESTON
Suffix:
Gender:M
Credentials:MD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 4TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3112
Mailing Address - Country:US
Mailing Address - Phone:321-409-0667
Mailing Address - Fax:321-409-0668
Practice Address - Street 1:122 4TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3112
Practice Address - Country:US
Practice Address - Phone:321-409-0667
Practice Address - Fax:321-409-0668
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172699-012085R0202X
FLME726782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF86163Medicare UPIN
FL418888Medicare ID - Type Unspecified