Healthcare Provider Details

I. General information

NPI: 1669679569
Provider Name (Legal Business Name): CHRISTOPHER MARK JOHN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

52 UNDERWOOD ST # 153
ORLANDO FL
32806-1110
US

V. Phone/Fax

Practice location:
  • Phone: 407-481-7174
  • Fax: 321-843-6080
Mailing address:
  • Phone: 321-841-2558
  • Fax: 407-849-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS15940
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20A20771
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberP0069
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: