Provider Demographics
NPI:1922309087
Name:MARK ELLIOTT HUPART DOCTOR OF PODIATRIC MEDICINE LLC
Entity Type:Organization
Organization Name:MARK ELLIOTT HUPART DOCTOR OF PODIATRIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:HUPART
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-704-9704
Mailing Address - Street 1:2123 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6101
Mailing Address - Country:US
Mailing Address - Phone:917-704-9704
Mailing Address - Fax:718-241-5764
Practice Address - Street 1:2123 E 70TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6101
Practice Address - Country:US
Practice Address - Phone:917-704-9704
Practice Address - Fax:718-241-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004686213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01180363Medicaid
NY01180363Medicaid
NY06719Medicare PIN