Healthcare Provider Details

I. General information

NPI: 1710902606
Provider Name (Legal Business Name): MARK KENNETH DICARLO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S KANNER HWY STE 200
STUART FL
34994-4801
US

IV. Provider business mailing address

PO BOX 417
STUART FL
34995-0417
US

V. Phone/Fax

Practice location:
  • Phone: 772-219-4026
  • Fax: 772-283-4919
Mailing address:
  • Phone: 772-223-5665
  • Fax: 772-223-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3676
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: