Provider Demographics
NPI:1497028229
Name:DIRLAM, MARK (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DIRLAM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 HENDRICKS BLVD
Mailing Address - Street 2:
Mailing Address - City:EGGERTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3301
Mailing Address - Country:US
Mailing Address - Phone:716-343-5157
Mailing Address - Fax:
Practice Address - Street 1:2438 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2244
Practice Address - Country:US
Practice Address - Phone:716-873-9154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034320-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist