Provider Demographics
NPI:1245291020
Name:BRANDWEIN, MARK EVAN (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EVAN
Last Name:BRANDWEIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BROADWAY
Mailing Address - Street 2:#907C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2608
Mailing Address - Country:US
Mailing Address - Phone:212-219-0284
Mailing Address - Fax:
Practice Address - Street 1:611 BROADWAY
Practice Address - Street 2:#907C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2608
Practice Address - Country:US
Practice Address - Phone:212-219-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003719-1111N00000X
NJMC04210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X21061Medicare ID - Type Unspecified