Healthcare Provider Details

I. General information

NPI: 1255409017
Provider Name (Legal Business Name): MARK A VULETICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S SHANNON AVE
INDIALANTIC FL
32903-3439
US

IV. Provider business mailing address

717 BOUNTY SQUARE DR
CHARLESTON SC
29492-8071
US

V. Phone/Fax

Practice location:
  • Phone: 321-213-0536
  • Fax:
Mailing address:
  • Phone: 843-814-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS8108
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTL1401
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: