Healthcare Provider Details

I. General information

NPI: 1801885348
Provider Name (Legal Business Name): NICOLE J MARK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 W HILLSBORO BLVD SUITE 110
COCONUT CREEK FL
33073-4395
US

IV. Provider business mailing address

5300 W HILLSBORO BLVD SUITE 110
COCONUT CREEK FL
33073-4395
US

V. Phone/Fax

Practice location:
  • Phone: 954-794-1360
  • Fax: 954-794-1367
Mailing address:
  • Phone: 954-794-1360
  • Fax: 954-794-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS8649
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: