=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518823863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MADDALENA LDO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2025
-----------------------------------------------------
Last Update Date | 12/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 288 LARKIN DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10950-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-783-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 RIDINGS LN
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10918-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-596-4244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 010766
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------