Provider Demographics
NPI:1780668657
Name:CAPPEL, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:CAPPEL
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 1:100 EXECUTIVE WAY STE 114
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2713
Mailing Address - Country:US
Mailing Address - Phone:904-842-3632
Mailing Address - Fax:877-624-3376
Practice Address - Street 1:100 EXECUTIVE WAY STE 114
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2713
Practice Address - Country:US
Practice Address - Phone:904-842-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93687207ND0101X, 207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN070000795Medicare PIN
FLU8796ZMedicare PIN
MNP00739693OtherRAILROAD MEDICARE
I65399Medicare UPIN
FL276233100Medicaid