Provider Demographics
NPI:1851488704
Name:FURSHPAN, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:FURSHPAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1322
Mailing Address - Country:US
Mailing Address - Phone:631-563-3162
Mailing Address - Fax:631-563-3185
Practice Address - Street 1:1563 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1322
Practice Address - Country:US
Practice Address - Phone:631-563-3162
Practice Address - Fax:631-563-3185
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008908103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY61010237344Medicaid
NYV295351Medicare ID - Type UnspecifiedPSYCHOLOGIST
NY61010237344Medicaid