Healthcare Provider Details

I. General information

NPI: 1104800408
Provider Name (Legal Business Name): MARK A RAIFMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S BERGEN PL
FREEPORT NY
11520-3528
US

IV. Provider business mailing address

PO BOX 390
FREEPORT NY
11520-0390
US

V. Phone/Fax

Practice location:
  • Phone: 516-442-7179
  • Fax: 516-442-7183
Mailing address:
  • Phone: 516-779-2390
  • Fax: 516-295-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number124183
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: