Provider Demographics
NPI:1528030269
Name:GUDESBLATT, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GUDESBLATT
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 1:712 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3620
Mailing Address - Country:US
Mailing Address - Phone:631-666-3939
Mailing Address - Fax:631-666-3994
Practice Address - Street 1:712 MAIN ST
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3620
Practice Address - Country:US
Practice Address - Phone:631-666-3939
Practice Address - Fax:631-666-3994
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1472272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158790Medicaid
23D141Medicare PIN
NYB11247Medicare UPIN