Provider Demographics
NPI:1013917301
Name:MARK, RON (MD)
Entity type:Individual
Prefix:DR
First Name:RON
Middle Name:
Last Name:MARK
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 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1319
Mailing Address - Country:US
Mailing Address - Phone:631-574-2060
Mailing Address - Fax:
Practice Address - Street 1:2103 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1319
Practice Address - Country:US
Practice Address - Phone:631-574-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMTM2010-06342085R0202X
NY2147732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02583631Medicaid
NYP00221729OtherRAILROAD MEDICARE
NY02583631Medicaid
I19511Medicare UPIN