Provider Demographics
NPI:1154559409
Name:MARK J ELDER DO PA
Entity type:Organization
Organization Name:MARK J ELDER DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO PA
Authorized Official - Phone:850-623-4070
Mailing Address - Street 1:5992 BERRYHILL RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-1013
Mailing Address - Country:US
Mailing Address - Phone:850-981-0320
Mailing Address - Fax:
Practice Address - Street 1:5992 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-1013
Practice Address - Country:US
Practice Address - Phone:850-981-0320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty