Healthcare Provider Details

I. General information

NPI: 1871557629
Provider Name (Legal Business Name): MARK H WIDICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 LINTON BLVD STE E2
DELRAY BEACH FL
33484-6595
US

IV. Provider business mailing address

900 NW 13TH ST SUITE 206
BOCA RATON FL
33486-2350
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-3333
  • Fax: 561-391-5618
Mailing address:
  • Phone: 561-338-3267
  • Fax: 561-391-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME65602
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberME65602
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: