Provider Demographics
NPI:1841460946
Name:JOLLY, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JOLLY
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 1:4201 14TH AVENUE EAST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208
Mailing Address - Country:US
Mailing Address - Phone:941-713-0728
Mailing Address - Fax:
Practice Address - Street 1:4201 14TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5815
Practice Address - Country:US
Practice Address - Phone:941-713-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 100262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine