Healthcare Provider Details

I. General information

NPI: 1487147823
Provider Name (Legal Business Name): MARK MALOOF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 MERRICK RD
OCEANSIDE NY
11572-1420
US

IV. Provider business mailing address

196 MERRICK RD
OCEANSIDE NY
11572-1420
US

V. Phone/Fax

Practice location:
  • Phone: 516-255-8400
  • Fax: 516-255-8450
Mailing address:
  • Phone: 516-255-8400
  • Fax: 516-255-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number311867
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: