Provider Demographics
NPI:1972589794
Name:GERSTEN, MARK BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BENJAMIN
Last Name:GERSTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MIDDLE NECK RD
Mailing Address - Street 2:APT 3B
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1158
Mailing Address - Country:US
Mailing Address - Phone:516-482-4174
Mailing Address - Fax:
Practice Address - Street 1:58 47 FRANCIS LEWIS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364
Practice Address - Country:US
Practice Address - Phone:718-229-6688
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00325484Medicaid
92624Medicare ID - Type UnspecifiedGHI MEDICARE
NY00325484Medicaid