Healthcare Provider Details

I. General information

NPI: 1013917301
Provider Name (Legal Business Name): RON MARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

V. Phone/Fax

Practice location:
  • Phone: 631-574-2060
  • Fax:
Mailing address:
  • Phone: 631-574-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36126885
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number214773
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberTM2010-0634
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: