Provider Demographics
NPI:1346416963
Name:CORONEL, MARK JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JACOB
Last Name:CORONEL
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 1:856 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2540
Mailing Address - Country:US
Mailing Address - Phone:631-591-3000
Mailing Address - Fax:
Practice Address - Street 1:287 WADING RIVER RD
Practice Address - Street 2:UNIT 2
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949
Practice Address - Country:US
Practice Address - Phone:631-591-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-03
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY454858453OtherNYS