Provider Demographics
NPI:1649250523
Name:KONICKI, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KONICKI
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:PO BOX 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-357-5627
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-364-3649
Practice Address - Fax:904-357-5627
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60881207R00000X
IN01071892A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373993799Medicaid
FLRAILROAD MEDICAREOtherP01551193
FL373993799Medicaid