Provider Demographics
NPI:1962586776
Name:WHITE, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:THE UROLOGICAL INSTITUTE OF NORTHEASTERN NEW YORK
Practice Address - Street 2:SOUTH CLINICAL CAMPUS, 23 HACKETT BLVD.
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199165208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862197Medicaid
NY01862197Medicaid
NYG77947Medicare UPIN