Provider Demographics
NPI:1558448571
Name:RYDZEWSKI, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RYDZEWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 61ST ST
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-2811
Mailing Address - Country:US
Mailing Address - Phone:718-894-9156
Mailing Address - Fax:718-692-8569
Practice Address - Street 1:5804 61ST ST
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2811
Practice Address - Country:US
Practice Address - Phone:718-894-9156
Practice Address - Fax:718-692-8569
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185061207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01477861Medicaid
NY110167260OtherRAILROAD
NY01477861Medicaid
110167260Medicare PIN
NY0076QCMedicare ID - Type Unspecified