Provider Demographics
NPI:1093704199
Name:MARK, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 3RD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6205
Mailing Address - Country:US
Mailing Address - Phone:732-229-3737
Mailing Address - Fax:732-229-5757
Practice Address - Street 1:279 3RD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6205
Practice Address - Country:US
Practice Address - Phone:732-229-3737
Practice Address - Fax:732-229-5757
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1134906Medicaid
NJ461828Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
NJ1134906Medicaid