Provider Demographics
NPI:1982665782
Name:GERSHENBAUM, MARK R (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GERSHENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13700-1901
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19191-1901
Mailing Address - Country:US
Mailing Address - Phone:800-777-2455
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:901 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-294-2666
Practice Address - Fax:732-431-8267
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04672200207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5453101Medicaid
P00153530OtherRAILROAD MEDICARE
P00153530OtherRAILROAD MEDICARE
NJ186636Medicare ID - Type Unspecified