Healthcare Provider Details

I. General information

NPI: 1033176805
Provider Name (Legal Business Name): MARK DAVID WASSERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 ROUTE 25A
MILLER PLACE NY
11764-2625
US

IV. Provider business mailing address

555 ROUTE 25A
MILLER PLACE NY
11764-2625
US

V. Phone/Fax

Practice location:
  • Phone: 631-744-6666
  • Fax: 631-744-0525
Mailing address:
  • Phone: 631-744-6666
  • Fax: 631-744-0525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number132521
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: