Provider Demographics
NPI:1376527929
Name:SOUWEIDANE, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:SOUWEIDANE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:525 E 68TH ST
Mailing Address - Street 2:BOX 99
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-2363
Mailing Address - Fax:212-746-7729
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:BOX 99
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4870
Practice Address - Country:US
Practice Address - Phone:212-746-2363
Practice Address - Fax:212-746-5592
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2015-07-09
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Provider Licenses
StateLicense IDTaxonomies
NY188037207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G15640Medicare UPIN
22E531Medicare ID - Type Unspecified