Healthcare Provider Details

I. General information

NPI: 1295744639
Provider Name (Legal Business Name): MARK A SMITH MD,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10095 BEACH BLVD STE 300
JACKSONVILLE FL
32246-4775
US

IV. Provider business mailing address

10095 BEACH BLVD STE 300
JACKSONVILLE FL
32246-4775
US

V. Phone/Fax

Practice location:
  • Phone: 904-997-2221
  • Fax: 904-997-2297
Mailing address:
  • Phone: 904-997-2221
  • Fax: 904-997-2297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME77870
License Number StateFL

VIII. Authorized Official

Name: DR. MARK ANTHONY SMITH
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 904-997-2221