Provider Demographics
NPI:1538199310
Name:MARK, KENNETH ANDRE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDRE
Last Name:MARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:365 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 14
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5284
Practice Address - Country:US
Practice Address - Phone:631-283-0002
Practice Address - Fax:631-283-1932
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204164207ND0101X, 207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2K3301Medicare ID - Type Unspecified
NYWZYPV1Medicare UPIN
NYH34850Medicare UPIN