Healthcare Provider Details

I. General information

NPI: 1538199310
Provider Name (Legal Business Name): KENNETH ANDRE MARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 COUNTY ROAD 39A SUITE 14
SOUTHAMPTON NY
11968-5284
US

IV. Provider business mailing address

PO BOX 175
WATER MILL NY
11976-0175
US

V. Phone/Fax

Practice location:
  • Phone: 631-283-0002
  • Fax: 631-283-1932
Mailing address:
  • Phone: 631-283-0002
  • Fax: 631-283-1932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number204164
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number204164
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number204164
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: