Provider Demographics
NPI:1841514924
Name:WHITED, MARK ADAM
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ADAM
Last Name:WHITED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7859
Mailing Address - Country:US
Mailing Address - Phone:941-798-8303
Mailing Address - Fax:
Practice Address - Street 1:6404 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7859
Practice Address - Country:US
Practice Address - Phone:941-798-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003957225100000X
FLPT32204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist