Healthcare Provider Details

I. General information

NPI: 1497998512
Provider Name (Legal Business Name): MARK DAVID EWALT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVENUE DEPT OF PATHOLOGY, BOX #36
NEW YORK NY
10065
US

IV. Provider business mailing address

1275 YORK AVENUE DEPT OF PATHOLOGY, BOX #36
NEW YORK NY
10065
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-8137
  • Fax:
Mailing address:
  • Phone: 212-639-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberDR.0058760
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA121762
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberDR.0058760
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberDR.0058760
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: