Provider Demographics
NPI:1104077064
Name:ZUNKIEWICZ, MARK RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:ZUNKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 206
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-231-4450
Mailing Address - Fax:386-231-4459
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 206
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-4450
Practice Address - Fax:386-231-4459
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35095661207X00000X, 207XX0005X
FLME134460207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3071143Medicaid
OH35095661OtherSTATE LICENSE
OHFZ0752332OtherDEA
OH3071143Medicaid