Basic Information
| Provider Information | |||||||||
| NPI: | 1992797237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | METZDORFF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | TERRANCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 722 W WATER ST | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149052435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712093 | ||||||||
| FaxNumber: | 6072712099 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 IVY ST | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077377780 | ||||||||
| FaxNumber: | 6077377788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/15/2013 | ||||||||
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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 | 208G00000X | MD13216 | OR | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | MD00029270 | WA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 271766 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 210476 | 05 | OR | MEDICAID | 8303331 | 05 | WA | MEDICAID |