Provider Demographics
NPI:1235635921
Name:WARD, MARK AUSTIN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:AUSTIN
Last Name:WARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1256
Mailing Address - Country:US
Mailing Address - Phone:228-860-2126
Mailing Address - Fax:
Practice Address - Street 1:3000 MEDICAL PARK DR STE 490
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-6600
Practice Address - Country:US
Practice Address - Phone:813-971-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.41868208600000X
390200000X
FL167668208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program