Provider Demographics
NPI:1679641617
Name:VANHUSEN, MARK JOHN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:VANHUSEN
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 1:8100 OSWEGO ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-9698
Practice Address - Street 1:8100 OSWEGO ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-9698
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
085000OtherMVP HEALTHCARE
NY01227063Medicaid
NY080178303OtherRAILROAD MEDICARE
CC7711Medicare ID - Type Unspecified
NY080178303OtherRAILROAD MEDICARE