Provider Demographics
NPI:1356309892
Name:ALLEN, MARC (DO)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 W JERICHO TPKE
Mailing Address - Street 2:STE 11
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3205
Mailing Address - Country:US
Mailing Address - Phone:631-543-8844
Mailing Address - Fax:631-543-8844
Practice Address - Street 1:358 VETERANS MEMORIAL HIGHWAY
Practice Address - Street 2:STE 11
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-543-8844
Practice Address - Fax:631-543-8840
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2238341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02238341Medicaid
NY02238341Medicaid
H63005Medicare UPIN