Provider Demographics
NPI:1699866814
Name:VAYSMAN, MARK (DPT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:VAYSMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 SEAGIRT BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2802
Mailing Address - Country:US
Mailing Address - Phone:347-244-2530
Mailing Address - Fax:
Practice Address - Street 1:2876 W 27TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2812
Practice Address - Country:US
Practice Address - Phone:718-265-2222
Practice Address - Fax:718-333-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02324376Medicaid
NY06768GOtherGHI MEDICARE PROVIDER #
NY023238OtherPROFFESIONAL LICENCE
QQ1541Medicare PIN
NY06768GOtherGHI MEDICARE PROVIDER #