Provider Demographics
NPI:1174730592
Name:LEITER, MARK ROBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:LEITER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:LEITER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:107 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1440
Mailing Address - Country:US
Mailing Address - Phone:515-382-3470
Mailing Address - Fax:516-569-7564
Practice Address - Street 1:107 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1440
Practice Address - Country:US
Practice Address - Phone:515-382-3470
Practice Address - Fax:516-569-7564
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO4255-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039005Medicaid
T51416Medicare UPIN