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General NPI Number Information
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NPI Number | 1992982748
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Entity Type | Organization
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Legal Business Name | KENNETH MARK MD PC
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Dates
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Enumeration Date | 01/23/2008
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 425 COUNTY ROAD 39A SUITE 201
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-5277
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Country | US
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Telephone | 631-283-0002
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Fax | 631-283-1932
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Provider Business Mailing Address
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Address Line | PO BOX 175
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City | WATER MILL
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State | NY
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Zip | 11976-0175
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Country | US
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Telephone | 631-283-0002
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Fax | 631-283-1932
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. KENNETH ANDRE MARK
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Credential | MD
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Telephone | 631-283-0002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 204164
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 204164
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 204164
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License Number State | NY
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