Provider Demographics
NPI:1750437828
Name:MEDICI, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MEDICI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 AIRPORT EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5238
Mailing Address - Country:US
Mailing Address - Phone:845-358-1000
Mailing Address - Fax:845-358-2155
Practice Address - Street 1:507 AIRPORT EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-5238
Practice Address - Country:US
Practice Address - Phone:845-262-5313
Practice Address - Fax:845-262-5330
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2030161207X00000X, 207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG93269Medicare UPIN
NYWFW361Medicare ID - Type UnspecifiedGROUP
NY84G581Medicare ID - Type UnspecifiedINDIVIDUAL