Provider Demographics
NPI:1386978724
Name:MIFSUD, MARK JOSEPH (OTR)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:MIFSUD
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1138
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1138
Mailing Address - Country:US
Mailing Address - Phone:917-647-9458
Mailing Address - Fax:
Practice Address - Street 1:75-20 ASTORIA BLVD.
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11370
Practice Address - Country:US
Practice Address - Phone:917-647-9458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002571225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation