Provider Demographics
NPI:1801836770
Name:REIFENSTEIN, MARK BENEDICT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BENEDICT
Last Name:REIFENSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 LONG POND ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606
Mailing Address - Country:US
Mailing Address - Phone:585-247-1777
Mailing Address - Fax:585-247-1778
Practice Address - Street 1:1770 LONG POND ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606
Practice Address - Country:US
Practice Address - Phone:585-247-1777
Practice Address - Fax:585-247-1778
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY184059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1840594WCFPOtherWORKERS COMP
NY01304443Medicaid
NY161475Medicare Oscar/Certification
NY01304443Medicaid
NYRA0092-GRP:BA0017Medicare PIN
NYF26195Medicare UPIN
NYI71019-GRP:70008AMedicare PIN