Provider Demographics
NPI:1932129863
Name:GHASSEMI, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GHASSEMI
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 1:721 CLIFTON AVENUE
Mailing Address - Street 2:UNIT 2A
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013
Mailing Address - Country:US
Mailing Address - Phone:973-777-7727
Mailing Address - Fax:973-779-7906
Practice Address - Street 1:721 CLIFTON AVENUE
Practice Address - Street 2:UNIT 2A
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-777-7727
Practice Address - Fax:973-779-7906
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA023699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1656201Medicaid
C56478Medicare UPIN
NJ488011Medicare PIN