Healthcare Provider Details

I. General information

NPI: 1225483621
Provider Name (Legal Business Name): RYAN MARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 112727
GAINESVILLE FL
32611-2727
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7002
  • Fax: 352-273-7388
Mailing address:
  • Phone: 352-273-7002
  • Fax: 352-273-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301116993
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME166965
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME166965
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301116993
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: