Healthcare Provider Details

I. General information

NPI: 1275980153
Provider Name (Legal Business Name): MARK GREGORY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 WESTERN RD
SOUTH DAYTONA FL
32119-1932
US

IV. Provider business mailing address

1718 WESTERN RD
SOUTH DAYTONA FL
32119-1932
US

V. Phone/Fax

Practice location:
  • Phone: 386-295-3159
  • Fax:
Mailing address:
  • Phone: 386-295-3159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number816376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: