=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295891588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TOBAK MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 HARRISON AVE SUITE 105A
-----------------------------------------------------
City | MAMARONECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10543-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-698-3018
-----------------------------------------------------
Fax | 914-698-0685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 HARRISON AVE SUITE 105A
-----------------------------------------------------
City | MAMARONECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10543-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-698-3018
-----------------------------------------------------
Fax | 914-698-0685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK TOBAK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 914-698-3018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------