Healthcare Provider Details

I. General information

NPI: 1578094322
Provider Name (Legal Business Name): MARK KAMINETZKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE RADIOLOGY DEPT
HACKENSACK NJ
07601
US

IV. Provider business mailing address

130 KINDERKAMACK RD STE 200
RIVER EDGE NJ
07661-1931
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2200
  • Fax:
Mailing address:
  • Phone: 201-488-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number299458
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA11762500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: