Provider Demographics
NPI:1316036601
Name:KIRSHNER, MARK DAVID (CPED, CO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:KIRSHNER
Suffix:
Gender:M
Credentials:CPED, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 JACK DANCE ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5576
Mailing Address - Country:US
Mailing Address - Phone:865-691-8381
Mailing Address - Fax:865-691-8574
Practice Address - Street 1:8823 PRODUCTION LN
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-6511
Practice Address - Country:US
Practice Address - Phone:423-238-7217
Practice Address - Fax:423-285-6647
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703026Medicaid
NC7703026Medicaid