Provider Demographics
NPI:1588640296
Name:WEBSTER, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:WEBSTER
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:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:NY
Mailing Address - Zip Code:13420-0207
Mailing Address - Country:US
Mailing Address - Phone:315-369-6619
Mailing Address - Fax:315-369-6533
Practice Address - Street 1:114 S SHORE RD
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:NY
Practice Address - Zip Code:13420-3500
Practice Address - Country:US
Practice Address - Phone:315-369-6619
Practice Address - Fax:315-369-6533
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0075950OtherGHI
NY441081441OtherRAILROAD MEDICARE
NY00552974Medicaid
NY441081441OtherRAILROAD MEDICARE
NY0075950OtherGHI