Provider Demographics
NPI:1750320172
Name:FAY, MARK DAVID (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:FAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 TOWN PLAZA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:904-222-3780
Mailing Address - Fax:
Practice Address - Street 1:465 TOWN PLAZA AVE STE B
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5190
Practice Address - Country:US
Practice Address - Phone:904-222-3780
Practice Address - Fax:904-306-5772
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04438225100000X
FLPT238742251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C799C811Medicare ID - Type UnspecifiedPHYSICAL THERPAY