Healthcare Provider Details

I. General information

NPI: 1053479816
Provider Name (Legal Business Name): MARK C JOSEPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 ROCKAWAY PKWY
BROOKLYN NY
11236
US

IV. Provider business mailing address

54 LAFAYETTE PL
WOODMERE NY
11598-2138
US

V. Phone/Fax

Practice location:
  • Phone: 718-927-0027
  • Fax: 516-791-6529
Mailing address:
  • Phone: 516-374-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number215069
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: