Provider Demographics
NPI:1780916213
Name:GILBERT, MARK THOMAS
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:GILBERT
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 1:31 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4356
Mailing Address - Country:US
Mailing Address - Phone:607-729-3414
Mailing Address - Fax:
Practice Address - Street 1:37 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:UM
Practice Address - Phone:607-722-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2043243423207Q00000X
NY20024323183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No183500000XPharmacy Service ProvidersPharmacist