Provider Demographics
NPI:1861573289
Name:LERMAN, MARK (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:LERMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PUTNAM HALL SOUTH CAMPUS
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-632-9510
Mailing Address - Fax:
Practice Address - Street 1:PUTNAM HALL SOUTH CAMPUS
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-632-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1996862084P0800X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400025898OtherMEDICARE PROVIDER NUMER