1275910812 NPI number — MARK WADDLE MD

Table of content: MARK WADDLE MD (NPI 1275910812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275910812 NPI number — MARK WADDLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADDLE
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275910812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 SAN PABLO RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-1865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7015 A C SKINNER PKWY BLDG 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-6932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-516-3737
Provider Business Practice Location Address Fax Number:
904-516-3738
Provider Enumeration Date:
05/04/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  ME129176 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4135G . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 024389600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P02093045 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: JL244Z . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".