Provider Demographics
NPI:1417920349
Name:EHRENPREIS, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:EHRENPREIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12012 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3105
Mailing Address - Country:US
Mailing Address - Phone:718-805-8534
Mailing Address - Fax:
Practice Address - Street 1:11203 QUEENS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5550
Practice Address - Country:US
Practice Address - Phone:718-805-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198300208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562894Medicaid
NY02502Medicare ID - Type Unspecified
NY01562894Medicaid
NY18T001Medicare PIN