Provider Demographics
NPI:1437156288
Name:PASS, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:PASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:DAVID
Other - Last Name:PASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-0116
Mailing Address - Country:US
Mailing Address - Phone:732-866-9922
Mailing Address - Fax:732-866-9970
Practice Address - Street 1:100 CRAIG RD
Practice Address - Street 2:SUITE 205A
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8787
Practice Address - Country:US
Practice Address - Phone:732-866-9922
Practice Address - Fax:732-866-9970
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2017-11-27
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-09-12
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07471500207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0036447Medicaid
NJ0036447Medicaid
NJ068736Medicare ID - Type Unspecified