Provider Demographics
NPI:1033176805
Name:WASSERMAN, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2625
Mailing Address - Country:US
Mailing Address - Phone:631-744-6666
Mailing Address - Fax:631-744-0525
Practice Address - Street 1:555 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2625
Practice Address - Country:US
Practice Address - Phone:631-744-6666
Practice Address - Fax:631-744-0525
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00651661Medicaid
NY339251Medicare PIN
NY00651661Medicaid