Provider Demographics
NPI:1992982748
Name:KENNETH MARK MD PC
Entity type:Organization
Organization Name:KENNETH MARK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-283-0002
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:WATER MILL
Mailing Address - State:NY
Mailing Address - Zip Code:11976-0175
Mailing Address - Country:US
Mailing Address - Phone:631-283-0002
Mailing Address - Fax:631-283-1932
Practice Address - Street 1:425 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5277
Practice Address - Country:US
Practice Address - Phone:631-283-0002
Practice Address - Fax:631-283-1932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETH MARK M.D. PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-23
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204164207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH34850Medicare UPIN
NYWZYPV1Medicare PIN
NY2K3301Medicare PIN