Provider Demographics
NPI:1407820368
Name:PERELMAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PERELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 E 24TH ST
Mailing Address - Street 2:APT #1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4901
Mailing Address - Country:US
Mailing Address - Phone:516-897-1000
Mailing Address - Fax:
Practice Address - Street 1:455 E BAY DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2301
Practice Address - Country:US
Practice Address - Phone:516-897-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214299173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01980703Medicaid
NY01980703Medicaid
NYH01344Medicare UPIN
NY12V152Medicare PIN