Provider Demographics
NPI:1134182694
Name:MARK, LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:
Last Name:MARK
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 1:3375 BURNS RD
Mailing Address - Street 2:S#208
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4349
Mailing Address - Country:US
Mailing Address - Phone:561-627-0004
Mailing Address - Fax:561-627-0203
Practice Address - Street 1:3375 BURNS RD
Practice Address - Street 2:S#208
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4349
Practice Address - Country:US
Practice Address - Phone:561-627-0004
Practice Address - Fax:561-627-0203
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55874Medicare UPIN
FL50866Medicare ID - Type Unspecified