Provider Demographics
NPI:1952460826
Name:REISMAN, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:REISMAN
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 1:520 E 70TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-9800
Mailing Address - Country:US
Mailing Address - Phone:646-962-5558
Mailing Address - Fax:212-746-8451
Practice Address - Street 1:520 E 70TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9800
Practice Address - Country:US
Practice Address - Phone:646-962-5558
Practice Address - Fax:212-746-8451
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164182207RC0000X, 207RI0011X, 207RI0011X
WAMD00031483207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952460826Medicaid
WA0231953OtherLNI
WAE64321Medicare UPIN
WA8884152Medicare PIN