Provider Demographics
NPI:1366510620
Name:HALTRECHT, MARK HARRIS (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HARRIS
Last Name:HALTRECHT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:215 ROCKAWAY TPKE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1216
Mailing Address - Country:US
Mailing Address - Phone:516-374-5024
Mailing Address - Fax:516-792-0619
Practice Address - Street 1:215 ROCKAWAY TPKE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1216
Practice Address - Country:US
Practice Address - Phone:516-374-5024
Practice Address - Fax:516-792-0619
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY242484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0258GLOtherGHI MEDICARE
NY02891752Medicaid
NY0258GLOtherGHI MEDICARE