Provider Demographics
NPI:1285980110
Name:GENCO, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GENCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7099
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:3488 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1545
Practice Address - Country:US
Practice Address - Phone:716-832-6207
Practice Address - Fax:716-832-3282
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13988207Q00000X
390200000X
NY281857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty