Provider Demographics
NPI:1295828275
Name:MARINO, MARK C (MA, PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:MARINO
Suffix:
Gender:M
Credentials:MA, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY.
Mailing Address - Street 2:BLDG. 22B
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-751-7988
Mailing Address - Fax:631-751-7989
Practice Address - Street 1:2500 NESCONSET HWY.
Practice Address - Street 2:BLDG. 22B
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-751-7988
Practice Address - Fax:631-751-7989
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0167201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQT0841OtherMEDICARE ID