Provider Demographics
NPI:1477584738
Name:HEALEY, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:HEALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-1055
Mailing Address - Fax:315-261-5043
Practice Address - Street 1:25 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-2196
Practice Address - Country:US
Practice Address - Phone:315-265-1055
Practice Address - Fax:315-261-5043
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0009894174400000X
NY285052208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTP00255993OtherRR MEDICARE
VT0VN2070Medicaid
VT0VN2070Medicaid
VTHX3942Medicare PIN