Provider Demographics
NPI:1396824306
Name:MARK WASSERMAN, MD
Entity Type:Organization
Organization Name:MARK WASSERMAN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-744-6666
Mailing Address - Street 1:555 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2625
Mailing Address - Country:US
Mailing Address - Phone:631-744-6666
Mailing Address - Fax:631-744-0525
Practice Address - Street 1:555 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2625
Practice Address - Country:US
Practice Address - Phone:631-744-6666
Practice Address - Fax:631-744-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty