Healthcare Provider Details

I. General information

NPI: 1033059803
Provider Name (Legal Business Name): MARK WANIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 66TH RD
FOREST HILLS NY
11375-2029
US

IV. Provider business mailing address

361 GRANDVIEW AVE # 1F
RIDGEWOOD NY
11385-1216
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-4352
  • Fax:
Mailing address:
  • Phone: 347-278-4887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: