Healthcare Provider Details

I. General information

NPI: 1669418554
Provider Name (Legal Business Name): MARK DAVID RUIZ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 BAY BRIDGE DR
GULF BREEZE FL
32561-4468
US

IV. Provider business mailing address

79 BAY BRIDGE DR
GULF BREEZE FL
32561-4468
US

V. Phone/Fax

Practice location:
  • Phone: 850-741-5438
  • Fax: 850-726-4784
Mailing address:
  • Phone: 850-741-5438
  • Fax: 850-726-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY10437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: