Provider Demographics
NPI:1790065910
Name:SHLOMOVICH, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SHLOMOVICH
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 1:826 MEEHAN AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-5509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3411 WAYNE AVE FL 8
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2552
Practice Address - Country:US
Practice Address - Phone:718-741-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267571208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics