Healthcare Provider Details

I. General information

NPI: 1043205545
Provider Name (Legal Business Name): MARK A LIVECCHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 MAX LEGGETT PKWY
JACKSONVILLE FL
32218-7273
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-456-8297
  • Fax: 904-244-9493
Mailing address:
  • Phone: 904-244-9092
  • Fax: 904-244-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number130640
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number130640
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number130640
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: