Provider Demographics
NPI:1104800408
Name:RAIFMAN, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:RAIFMAN
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-0390
Mailing Address - Country:US
Mailing Address - Phone:516-779-2390
Mailing Address - Fax:516-295-0317
Practice Address - Street 1:101 S BERGEN PL
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3528
Practice Address - Country:US
Practice Address - Phone:516-442-7179
Practice Address - Fax:516-442-7183
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD0233156Medicaid
NY317051Medicare ID - Type Unspecified
NYD0233156Medicaid