Healthcare Provider Details

I. General information

NPI: 1356471999
Provider Name (Legal Business Name): MARK JAMES CORSALE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5800
US

IV. Provider business mailing address

4740 N STATE ROAD 7 STE 201
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 954-486-4005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD12132
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number056532
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME58087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: