Provider Demographics
NPI:1538189287
Name:CHALOM, MARK MURAD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MURAD
Last Name:CHALOM
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 1:1231 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3268
Mailing Address - Country:US
Mailing Address - Phone:315-393-2295
Mailing Address - Fax:315-393-9604
Practice Address - Street 1:1231 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3268
Practice Address - Country:US
Practice Address - Phone:315-393-2295
Practice Address - Fax:315-393-9604
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31747BMedicare ID - Type Unspecified
NYB79270Medicare UPIN