Provider Demographics
NPI:1124247721
Name:WALTER, MARK VINCENT (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:VINCENT
Last Name:WALTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:15 PARADISE PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6905
Mailing Address - Country:US
Mailing Address - Phone:941-955-4325
Mailing Address - Fax:941-955-4395
Practice Address - Street 1:2365 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3808
Practice Address - Country:US
Practice Address - Phone:941-955-4325
Practice Address - Fax:941-955-4395
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL752512083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH07492Medicare UPIN