Provider Demographics
NPI:1255498580
Name:HOORNSTRA, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:HOORNSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-7470
Mailing Address - Country:US
Mailing Address - Phone:516-629-2454
Mailing Address - Fax:516-629-2027
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:DEPT. OF EMERENCY MEDICINE
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-562-6605
Practice Address - Fax:516-629-2027
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY187340-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01298902Medicaid
NY01298902Medicaid
NY15G943Medicare ID - Type Unspecified