Provider Demographics
NPI:1801066188
Name:MARK G WARREN D P M P A
Entity type:Organization
Organization Name:MARK G WARREN D P M P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-715-3106
Mailing Address - Street 1:821 SW 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-8514
Mailing Address - Country:US
Mailing Address - Phone:561-715-3106
Mailing Address - Fax:561-336-4245
Practice Address - Street 1:5130 LINTON BLVD STE D3
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6595
Practice Address - Country:US
Practice Address - Phone:561-715-3106
Practice Address - Fax:561-336-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1194213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04125710-0Medicaid
FL04125710-0Medicaid
FL4476330001Medicare NSC
FLAK295Medicare PIN