Basic Information
| Provider Information | |||||||||
| NPI: | 1518931989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAZEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3085 HARLEM ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 HARLEM ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 208800000X | 191098 | NY | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 191098-1 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 005247231 | 01 | NY | BLUE CROSS | OTHER | 01739899 | 05 | NY | MEDICAID | 160985156 | 01 | UHC-EMPIRE | OTHER | 1908966 | 01 | NM | INDEPENDENT HEALTH INS | OTHER | 340013524 | 01 | NY | RAILROAD MEDICARE | OTHER | 00010297801 | 01 | NY | UNIVERA INSURANCE | OTHER | 1099639 | 01 | NY | GHI | OTHER |