Healthcare Provider Details

I. General information

NPI: 1720082647
Provider Name (Legal Business Name): MARK EVAN PUGACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 NORTHERN BLVD SUITE 102
GREAT NECK NY
11021-5100
US

IV. Provider business mailing address

560 NORTHERN BLVD STE 102
GREAT NECK NY
11021-5100
US

V. Phone/Fax

Practice location:
  • Phone: 516-504-1600
  • Fax: 516-504-6398
Mailing address:
  • Phone: 516-504-1600
  • Fax: 516-504-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number193865
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: