Provider Demographics
NPI:1932174091
Name:SCHROEDER, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SCHROEDER
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 1:1005 COLLEGE BLVD W
Mailing Address - Street 2:SUITE C
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1053
Mailing Address - Country:US
Mailing Address - Phone:850-678-3994
Mailing Address - Fax:
Practice Address - Street 1:1005 COLLEGE BLVD W
Practice Address - Street 2:SUITE C
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1053
Practice Address - Country:US
Practice Address - Phone:850-678-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE65968Medicare UPIN
FL029050155Medicare ID - Type Unspecified