Provider Demographics
NPI:1750386744
Name:EBERBACH, MARK ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:EBERBACH
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 1:14012 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1165
Mailing Address - Country:US
Mailing Address - Phone:727-868-4490
Mailing Address - Fax:727-869-7085
Practice Address - Street 1:14012 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1165
Practice Address - Country:US
Practice Address - Phone:727-868-4490
Practice Address - Fax:727-869-7085
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07923OtherBLUE CROSS BLUE SHIELD
FLE31250Medicare UPIN
FL07923OtherBLUE CROSS BLUE SHIELD