Provider Demographics
NPI:1265553309
Name:FORNES, MARK (DC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FORNES
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 1:190 NORTH LONG BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520
Mailing Address - Country:US
Mailing Address - Phone:516-623-4397
Mailing Address - Fax:
Practice Address - Street 1:125 W 16TH ST
Practice Address - Street 2:#117
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-741-9660
Practice Address - Fax:212-741-9660
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0041411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor