Provider Demographics
NPI:1003934035
Name:HOMONOFF, MARK CARLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CARLIN
Last Name:HOMONOFF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:70 RIVERSIDE DR APT 6H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5716
Mailing Address - Country:US
Mailing Address - Phone:212-580-8235
Mailing Address - Fax:
Practice Address - Street 1:755 N BROADWAY STE 417
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-1083
Practice Address - Country:US
Practice Address - Phone:914-366-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLTPME2352084N0400X
KY544432084N0400X
GA864762084N0400X
AZ608552084N0400X
IN01084726A2084N0400X
NC2020-034852084N0400X
VA01012684612084N0400X
CAG1376932084N0400X
TXQ89082084N0400X
NY1243602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761100Medicaid