Provider Demographics
NPI:1740275361
Name:BISHOP, MARDI JANE (MD)
Entity type:Individual
Prefix:MS
First Name:MARDI
Middle Name:JANE
Last Name:BISHOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:841 LAKEWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1319 S INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 1151
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1408
Practice Address - Country:US
Practice Address - Phone:407-333-1616
Practice Address - Fax:407-333-1617
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054596A207VX0000X
FLME94808207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37022OtherBCBS FL
FL274559300Medicaid