Provider Demographics
NPI:1689656399
Name:TANENBAUM, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E 52ND ST
Mailing Address - Street 2:APT 7BC
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-9033
Mailing Address - Country:US
Mailing Address - Phone:718-627-0585
Mailing Address - Fax:718-228-4930
Practice Address - Street 1:1648 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1175
Practice Address - Country:US
Practice Address - Phone:718-627-0585
Practice Address - Fax:718-228-4930
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003136213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00540987Medicaid
NY00540987Medicaid
NYP33781Medicare ID - Type Unspecified
NY4334040001Medicare NSC
NY00540987Medicaid