MEDICARE: DR. MARK EDMUND PESSA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0127X	Trauma Surgery Physician	ME94760	FL
2	208600000X	Surgery Physician	ME94760	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	31607X	OTHER	FL	MEDICARE HFPSI
3	31607Y	OTHER	FL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174526958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDMUND PESSA M.D.

Provider Business Mailing Address
First Line	:	3300 S FISKE BLVD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-4306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 HICKORY ST
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-3224
Country	:	US
Telephone Number	:	321-434-1401
Fax Number	:	321-434-1667

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/15/2023

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Directions to “ DR. MARK EDMUND PESSA M.D.” Practice Location

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