Provider Demographics
NPI:1568499465
Name:WEINER, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:WEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:505 E 70TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:212-746-2900
Mailing Address - Fax:215-707-3644
Practice Address - Street 1:505 E 70TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-746-2900
Practice Address - Fax:212-746-4609
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053756L207R00000X
NY300121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015348450009Medicaid
PA0015348450009Medicaid
G09234Medicare UPIN