Provider Demographics
NPI:1295744639
Name:MARK A SMITH MD,P.A.
Entity type:Organization
Organization Name:MARK A SMITH MD,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-997-2221
Mailing Address - Street 1:10095 BEACH BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4775
Mailing Address - Country:US
Mailing Address - Phone:904-997-2221
Mailing Address - Fax:904-997-2297
Practice Address - Street 1:10095 BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4775
Practice Address - Country:US
Practice Address - Phone:904-997-2221
Practice Address - Fax:904-997-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77870207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871558114OtherINDIVIDUAL PRACTITIONER
FL1871558114OtherINDIVIDUAL PRACTITIONER