Provider Demographics
NPI:1144259425
Name:KIRSCHENBAUM, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:KIRSCHENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3952
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:104 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2502
Practice Address - Country:US
Practice Address - Phone:201-670-4664
Practice Address - Fax:201-670-8007
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA04933400207RC0000X
NJ25MA04933400207R00000X
NY155240207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01113533Medicaid
NJ3396100Medicaid
NJ500772MBQMedicare ID - Type Unspecified
NJ3396100Medicaid
NY01113533Medicaid