Provider Demographics
NPI:1386668010
Name:VINE, MARK H (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:VINE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:137 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1312
Mailing Address - Country:US
Mailing Address - Phone:516-561-6200
Mailing Address - Fax:516-561-7112
Practice Address - Street 1:123 MAPLE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2240
Practice Address - Country:US
Practice Address - Phone:516-561-6200
Practice Address - Fax:516-561-7112
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2015-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY127841208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00382650Medicaid
NY00382650Medicaid
NY03876AMedicare PIN