Provider Demographics
NPI:1689615601
Name:DURBACK, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DURBACK
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 1:21 CORPORATE DRIVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2664
Mailing Address - Country:US
Mailing Address - Phone:610-250-9605
Mailing Address - Fax:610-250-3902
Practice Address - Street 1:21 CORPORATE DRIVE
Practice Address - Street 2:SUITE 6
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2664
Practice Address - Country:US
Practice Address - Phone:610-250-9605
Practice Address - Fax:610-250-3902
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027186E207RR0500X
NJMA51321207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001122106Medicaid
NJ2463105Medicaid
PADU100195Medicare ID - Type Unspecified
PA001122106Medicaid
NJ2463105Medicaid