Provider Demographics
NPI:1295893295
Name:MARIN, EDGAR L (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:L
Last Name:MARIN
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 1:285 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE LL-5
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2980
Mailing Address - Country:US
Mailing Address - Phone:631-265-6717
Mailing Address - Fax:631-265-6714
Practice Address - Street 1:285 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE LL-5
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2980
Practice Address - Country:US
Practice Address - Phone:631-265-6717
Practice Address - Fax:631-265-6714
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131675208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00907644Medicaid
NYC04471Medicare UPIN
NY00907644Medicaid