Provider Demographics
NPI:1407948029
Name:MEAD, MARK B
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:MEAD
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 1:10813 STATE ROUTE 90
Mailing Address - Street 2:
Mailing Address - City:LOCKE
Mailing Address - State:NY
Mailing Address - Zip Code:13092-3285
Mailing Address - Country:US
Mailing Address - Phone:607-898-5827
Mailing Address - Fax:607-898-9726
Practice Address - Street 1:100 SYKES ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-1231
Practice Address - Country:US
Practice Address - Phone:607-898-5827
Practice Address - Fax:607-898-9726
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007106-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02055512Medicaid
NYCC0105Medicare ID - Type Unspecified
NY02055512Medicaid