Healthcare Provider Details

I. General information

NPI: 1508986936
Provider Name (Legal Business Name): MARK A MESSINESE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 16TH AVE S
JACKSONVILLE BEACH FL
32250-3213
US

IV. Provider business mailing address

1127 16TH AVE S
JACKSONVILLE BEACH FL
32250-3213
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-7778
  • Fax: 904-241-9673
Mailing address:
  • Phone: 904-247-7778
  • Fax: 904-241-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME64038
License Number StateFL

VIII. Authorized Official

Name: MARK A. MESSINESE
Title or Position: PRESIDENT
Credential: MD
Phone: 904-247-7778