Provider Demographics
NPI:1487768511
Name:NEWBERRY, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:NEWBERRY
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 1:602 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-1442
Mailing Address - Country:US
Mailing Address - Phone:850-539-4747
Mailing Address - Fax:850-539-4744
Practice Address - Street 1:602 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-1442
Practice Address - Country:US
Practice Address - Phone:850-539-4747
Practice Address - Fax:850-539-4744
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55545207Q00000X
FLME0055545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061981700Medicaid
FLME0055545OtherSTATE LICENSE NUMBER
FLBN1965752OtherDEA NUMBER
FLME0055545OtherSTATE LICENSE NUMBER
FLE98846Medicare UPIN