Provider Demographics
NPI:1154494003
Name:TIEMAN, MARK DARYL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DARYL
Last Name:TIEMAN
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 1:34 COPPERDALE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2523
Mailing Address - Country:US
Mailing Address - Phone:631-858-0400
Mailing Address - Fax:631-543-2785
Practice Address - Street 1:356 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4332
Practice Address - Country:US
Practice Address - Phone:631-858-0400
Practice Address - Fax:631-543-2785
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY179172OtherM.D. LICENSE NUMBER
NY179172OtherM.D. LICENSE NUMBER
NY179172OtherM.D. LICENSE NUMBER
NY48F341Medicare ID - Type Unspecified