Healthcare Provider Details

I. General information

NPI: 1396824306
Provider Name (Legal Business Name): MARK WASSERMAN, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/31/2007
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: MARK WASSERMAN
Title or Position: MD
Credential: MD
Phone: 631-744-6666