MEDICARE: MARK ALAN TATAR PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	009456	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043428147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ALAN TATAR PH.D.

Provider Business Mailing Address
First Line	:	9 CAYUGA CT
Second Line	:
City	:	AVERILL PARK
State	:	NY
Zip	:	12018-9672
Country	:	US
Telephone Number	:	518-674-0528
Fax Number	:	518-674-0528

Provider Business Practice Location Address
First Line	:	726 COLUMBIA TPKE
Second Line	:
City	:	EAST GREENBUSH
State	:	NY
Zip	:	12061-2215
Country	:	US
Telephone Number	:	518-674-0528
Fax Number	:	518-674-0528

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	07/08/2007

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