Provider Demographics
NPI:1902997364
Name:BUTHORN, MARK FREDERICK JR (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FREDERICK
Last Name:BUTHORN
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 HEMPSTEAD TPKE
Mailing Address - Street 2:STE 110
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3636
Mailing Address - Country:US
Mailing Address - Phone:516-352-4454
Mailing Address - Fax:
Practice Address - Street 1:925 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3641
Practice Address - Country:US
Practice Address - Phone:516-352-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002200213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P24661Medicare ID - Type Unspecified
T93423Medicare UPIN