Provider Demographics
NPI:1881669281
Name:VARALLO, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:VARALLO
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:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-1207
Mailing Address - Country:US
Mailing Address - Phone:716-438-0822
Mailing Address - Fax:716-438-0822
Practice Address - Street 1:670 DAVISON RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5338
Practice Address - Country:US
Practice Address - Phone:716-438-0822
Practice Address - Fax:716-438-0822
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1995472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3103079002OtherGHI
NY00020919101OtherUNIVERA
NY01564007Medicaid
NY1590239OtherINDEPENDENT HEALTH
NY000523692001OtherBLUE CROSS./ BLUE SHIELD
NY3103079002OtherGHI
NYG05489Medicare UPIN