Healthcare Provider Details

I. General information

NPI: 1316905532
Provider Name (Legal Business Name): MARK MASTERS PH. D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 CORPORATE SQUARE BLVD
JACKSONVILLE FL
32216-1940
US

IV. Provider business mailing address

1905 CORPORATE SQUARE BLVD
JACKSONVILLE FL
32216-1940
US

V. Phone/Fax

Practice location:
  • Phone: 904-720-0599
  • Fax: 904-720-5225
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0004759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: