Provider Demographics
NPI:1508989435
Name:INDELICATO, MARK GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GEORGE
Last Name:INDELICATO
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 1:35 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2805
Mailing Address - Country:US
Mailing Address - Phone:917-575-4859
Mailing Address - Fax:
Practice Address - Street 1:111 FOUNDERS PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3212
Practice Address - Country:US
Practice Address - Phone:860-282-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230300207L00000X
CT044388207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology