Provider Demographics
NPI:1386775393
Name:MARK S WAXMAN MD PC
Entity type:Organization
Organization Name:MARK S WAXMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-997-6776
Mailing Address - Street 1:312 BELLEVILLE TPKE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-6463
Mailing Address - Country:US
Mailing Address - Phone:201-997-6776
Mailing Address - Fax:201-997-6610
Practice Address - Street 1:312 BELLEVILLE TPKE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6463
Practice Address - Country:US
Practice Address - Phone:201-997-6776
Practice Address - Fax:201-997-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03630700207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD20035Medicare UPIN
108280Medicare ID - Type Unspecified