Provider Demographics
NPI:1043428147
Name:TATAR, MARK ALAN (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:TATAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAYUGA CT
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018-9672
Mailing Address - Country:US
Mailing Address - Phone:518-674-0528
Mailing Address - Fax:518-674-0528
Practice Address - Street 1:726 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-2215
Practice Address - Country:US
Practice Address - Phone:518-674-0528
Practice Address - Fax:518-674-0528
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01605710Medicaid
NYR55369Medicare UPIN
NYCC9520Medicare ID - Type Unspecified