Healthcare Provider Details

I. General information

NPI: 1245764133
Provider Name (Legal Business Name): MARK NICHOLAS BRINKMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463380 STATE ROAD 200 UNIT B
YULEE FL
32097-3240
US

IV. Provider business mailing address

330 CORPORATE WAY STE 200
ORANGE PARK FL
32073-6214
US

V. Phone/Fax

Practice location:
  • Phone: 904-326-8050
  • Fax: 904-326-8051
Mailing address:
  • Phone: 904-282-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS16763
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: