Provider Demographics
NPI:1942479324
Name:STADLEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STADLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:3803 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4058
Practice Address - Country:US
Practice Address - Phone:718-956-3000
Practice Address - Fax:718-204-0227
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0040201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMS0C329210OtherBCBS
NY00695345Medicaid
NY0835910001Medicare NSC
NY42262Medicare PIN