Healthcare Provider Details

I. General information

NPI: 1396729810
Provider Name (Legal Business Name): MARK PAUL PRESTON M.D., J.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 4TH AVE SUITE 100
INDIALANTIC FL
32903-3112
US

IV. Provider business mailing address

122 4TH AVE SUITE 100
INDIALANTIC FL
32903-3112
US

V. Phone/Fax

Practice location:
  • Phone: 321-409-0667
  • Fax: 321-409-0668
Mailing address:
  • Phone: 321-409-0667
  • Fax: 321-409-0668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number172699-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME72678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: