Provider Demographics
NPI:1669415238
Name:MARK, GLEN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ROBERT
Last Name:MARK
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 1:633 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2789
Mailing Address - Country:US
Mailing Address - Phone:631-727-3795
Mailing Address - Fax:631-727-1961
Practice Address - Street 1:633 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2727
Practice Address - Country:US
Practice Address - Phone:631-727-3795
Practice Address - Fax:631-727-1961
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXOO7337-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO-7337-1OtherWORKERS COMPENSATION
NYCO-7337-1OtherWORKERS COMPENSATION
NYX65811Medicare ID - Type Unspecified