Provider Demographics
NPI:1831222165
Name:FRISK, MARK S (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:FRISK
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 1:350 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5136
Mailing Address - Country:US
Mailing Address - Phone:904-247-2220
Mailing Address - Fax:904-247-2296
Practice Address - Street 1:350 10TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5136
Practice Address - Country:US
Practice Address - Phone:904-247-2220
Practice Address - Fax:904-247-2296
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068458174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2240835OtherAETNA GROUP #
FLV2353OtherBCBS GROPU #
FL2240835OtherAETNA GROUP #
FLE3580Medicare ID - Type UnspecifiedMEDICARE GROUP #