Provider Demographics
NPI:1902992274
Name:PRESTON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PRESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:60 WESTWOOD AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-574-5501
Mailing Address - Fax:203-596-0912
Practice Address - Street 1:60 WESTWOOD AVE
Practice Address - Street 2:STE 200
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-574-5501
Practice Address - Fax:203-596-0912
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT040237207VG0400X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001402370Medicaid
H19595Medicare UPIN