Healthcare Provider Details

I. General information

NPI: 1568435030
Provider Name (Legal Business Name): MARK EDWARD ATES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 WOODBINE RD STE A
PACE FL
32571-8791
US

IV. Provider business mailing address

5447 N MURPHY RD
JAY FL
32565-1213
US

V. Phone/Fax

Practice location:
  • Phone: 850-994-6575
  • Fax:
Mailing address:
  • Phone: 850-675-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 58502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: