Provider Demographics
NPI:1164846085
Name:DOCTOR MARK PHYSICIAN PC
Entity Type:Organization
Organization Name:DOCTOR MARK PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYNKHADLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-541-6241
Mailing Address - Street 1:3612 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2710
Mailing Address - Country:US
Mailing Address - Phone:347-541-6241
Mailing Address - Fax:718-764-1229
Practice Address - Street 1:1502 E 14TH ST
Practice Address - Street 2:STE 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7283
Practice Address - Country:US
Practice Address - Phone:347-541-6241
Practice Address - Fax:718-764-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty