Provider Demographics
NPI:1104866318
Name:KRITCHEVSKY, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KRITCHEVSKY
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:VA MEDICAL CENTER 3350 LA JOLLA VILLAGE DRIVE (912
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:858-642-3685
Mailing Address - Fax:858-552-7513
Practice Address - Street 1:UCSD MEDICAL CENTER
Practice Address - Street 2:200 WEST ARBOR DRIVE MC 8201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8201
Practice Address - Country:US
Practice Address - Phone:858-657-8540
Practice Address - Fax:619-543-3183
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG381552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G381550Medicaid
CA00G381550Medicaid
CAA91967Medicare UPIN