Healthcare Provider Details

I. General information

NPI: 1770544777
Provider Name (Legal Business Name): MARK HARDIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

IV. Provider business mailing address

PO BOX 637
ORANGE PARK FL
32067-0637
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-7815
  • Fax:
Mailing address:
  • Phone: 904-388-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS 5218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: