Provider Demographics
NPI:1144651209
Name:MARK J ELDER DO PA
Entity type:Organization
Organization Name:MARK J ELDER DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-981-0320
Mailing Address - Street 1:3887 SCOTTS PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-4001
Mailing Address - Country:US
Mailing Address - Phone:850-981-0320
Mailing Address - Fax:850-981-0911
Practice Address - Street 1:3887 SCOTTS PLAZA DR
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-4001
Practice Address - Country:US
Practice Address - Phone:850-981-0320
Practice Address - Fax:850-981-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262643800Medicaid
FL262643800Medicaid
FLHS620AMedicare UPIN