Healthcare Provider Details

I. General information

NPI: 1154649861
Provider Name (Legal Business Name): MARK D BEDARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SMITH ST CREDENTIALING DEPARTMENT
ORANGE PARK FL
32073-5554
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2140
  • Fax: 904-264-3018
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS 12071
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: