Provider Demographics
NPI:1982629655
Name:OESTREICHER, MARK IAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:IAN
Last Name:OESTREICHER
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 1:160 HAWLEY LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5300
Mailing Address - Country:US
Mailing Address - Phone:203-377-0639
Mailing Address - Fax:
Practice Address - Street 1:160 HAWLEY LN
Practice Address - Street 2:SUITE 104
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-5300
Practice Address - Country:US
Practice Address - Phone:203-377-0639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021118207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT070000106Medicare ID - Type Unspecified
CT070000290Medicare ID - Type Unspecified
CTB39078Medicare UPIN