Provider Demographics
NPI:1275912495
Name:STEPHEN, MARK ABIAH (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ABIAH
Last Name:STEPHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18507 64TH AVE BSMT MEDICAL
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2707
Mailing Address - Country:US
Mailing Address - Phone:347-368-6222
Mailing Address - Fax:347-368-6291
Practice Address - Street 1:18507 64TH AVE BSMT MEDICAL
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2707
Practice Address - Country:US
Practice Address - Phone:347-368-6222
Practice Address - Fax:347-368-6291
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290169207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1275912495Medicaid