Provider Demographics
NPI:1972589463
Name:ISACOFF, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ISACOFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-1729
Mailing Address - Country:US
Mailing Address - Phone:516-825-2217
Mailing Address - Fax:
Practice Address - Street 1:1047 ROBIN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-1729
Practice Address - Country:US
Practice Address - Phone:516-825-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009895103TC0700X
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6804070OtherGHI PROVIDER NUMBER
NYR52803Medicare UPIN
NY04167Medicare PIN