Provider Demographics
NPI:1457700577
Name:SOHL, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SOHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BRENTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1002
Mailing Address - Country:US
Mailing Address - Phone:518-848-0801
Mailing Address - Fax:
Practice Address - Street 1:3 BRENTWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1002
Practice Address - Country:US
Practice Address - Phone:518-848-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03352834Medicaid