Provider Demographics
NPI:1295830057
Name:MEISEL, MARK KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KENNETH
Last Name:MEISEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-2209
Mailing Address - Country:US
Mailing Address - Phone:201-445-8884
Mailing Address - Fax:201-445-1932
Practice Address - Street 1:316 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-2209
Practice Address - Country:US
Practice Address - Phone:201-445-8884
Practice Address - Fax:201-445-1932
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03290100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07632OtherHEALTHNET
BP316OtherOXFORD
4093126OtherAETNA
4093126OtherAETNA
BP316OtherOXFORD