Healthcare Provider Details

I. General information

NPI: 1356314934
Provider Name (Legal Business Name): MARK ERIC WHITESIDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SIMONTON ST
KEY WEST FL
33040-3110
US

IV. Provider business mailing address

1735 BAHAMA DR
KEY WEST FL
33040-5217
US

V. Phone/Fax

Practice location:
  • Phone: 305-809-5280
  • Fax: 305-293-1561
Mailing address:
  • Phone: 305-293-8294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME0036940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: