Provider Demographics
NPI:1497981955
Name:FANO, MARK D (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:FANO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1135 CLIFTON AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3642
Mailing Address - Country:US
Mailing Address - Phone:973-928-3575
Mailing Address - Fax:973-928-3574
Practice Address - Street 1:1135 CLIFTON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3642
Practice Address - Country:US
Practice Address - Phone:973-928-3575
Practice Address - Fax:973-928-3574
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00430500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ188467Medicare PIN