Provider Demographics
NPI:1396719894
Name:WAXMAN, MARK STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:WAXMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 MCDONOUGH PL
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4226
Mailing Address - Country:US
Mailing Address - Phone:973-228-9171
Mailing Address - Fax:201-997-6610
Practice Address - Street 1:312 BELLEVILLE TPKE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6463
Practice Address - Country:US
Practice Address - Phone:201-997-6776
Practice Address - Fax:201-997-6610
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03630700207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60133446Medicaid
NJ457371V7ZMedicare ID - Type Unspecified