Basic Information
| Provider Information | |||||||||
| NPI: | 1467896480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUARESIMA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 1448 ROUTE 9 | ||||||||
| Address2: | |||||||||
| City: | SOUTH GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128031285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187616961 | ||||||||
| FaxNumber: | 5187611006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2013 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 278739 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04238166 | 05 | NY | MEDICAID |