Provider Demographics
NPI:1962441154
Name:PANISH, MARK B (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:PANISH
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 1:441 9TH AVE
Mailing Address - Street 2:FL 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1623
Mailing Address - Country:US
Mailing Address - Phone:646-680-4692
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:226 CLINTON ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2614
Practice Address - Country:US
Practice Address - Phone:516-483-2020
Practice Address - Fax:516-560-1895
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147977207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01723115Medicaid
NY32D112Medicare ID - Type Unspecified
NY01723115Medicaid