Provider Demographics
NPI:1629150792
Name:ST MARIE, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:ST MARIE
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 1:888 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224
Mailing Address - Country:US
Mailing Address - Phone:716-671-2130
Mailing Address - Fax:716-671-5346
Practice Address - Street 1:888 CENTER RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-671-2130
Practice Address - Fax:716-671-5346
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11489DMedicare ID - Type Unspecified
NYE35757Medicare UPIN