Provider Demographics
NPI:1376515833
Name:FEDERBUSCH, MARC JEFFREY (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:JEFFREY
Last Name:FEDERBUSCH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SHELLY CT
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5309
Mailing Address - Country:US
Mailing Address - Phone:516-822-3649
Mailing Address - Fax:516-681-3411
Practice Address - Street 1:6534 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6212
Practice Address - Country:US
Practice Address - Phone:718-366-3338
Practice Address - Fax:718-366-2633
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003554213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP3601699OtherOXFORD
NY00832242Medicaid
NYP3601699OtherOXFORD
T32190Medicare UPIN
NY00832242Medicaid
NY95208Medicare ID - Type UnspecifiedGHI