Provider Demographics
NPI:1750330049
Name:GRUDMAN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRUDMAN
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 1:393 SUNRISE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-5909
Mailing Address - Country:US
Mailing Address - Phone:631-228-5540
Mailing Address - Fax:631-396-6861
Practice Address - Street 1:393 SUNRISE HIGHWAY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-5909
Practice Address - Country:US
Practice Address - Phone:631-228-5540
Practice Address - Fax:631-396-6861
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192167207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762716Medicaid
NY24N011Medicare ID - Type Unspecified
NY01762176Medicaid