Provider Demographics
NPI:1841217312
Name:FARID, MARK BASIL (CERTIFIED PEDORTHIS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:BASIL
Last Name:FARID
Suffix:
Gender:M
Credentials:CERTIFIED PEDORTHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5455
Mailing Address - Country:US
Mailing Address - Phone:718-948-6353
Mailing Address - Fax:718-948-6257
Practice Address - Street 1:300 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5455
Practice Address - Country:US
Practice Address - Phone:718-948-6353
Practice Address - Fax:718-948-6257
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NO LICENSE REQUIRED174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01549480Medicaid
NY0846320001Medicare NSC