Provider Demographics
NPI:1952441586
Name:NATHANSON, MARK NEIL (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NEIL
Last Name:NATHANSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLOSTER DOCK RD
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1928
Mailing Address - Country:US
Mailing Address - Phone:201-784-1900
Mailing Address - Fax:201-784-8785
Practice Address - Street 1:200 CLOSTER DOCK RD
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-1928
Practice Address - Country:US
Practice Address - Phone:201-784-1900
Practice Address - Fax:201-784-8785
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00221000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6354270001Medicare NSC
NJU-43809Medicare UPIN
NJNA 122520Medicare ID - Type UnspecifiedMEDICARE NUMBER