Provider Demographics
NPI:1326231457
Name:KIRK, MARK S (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:KIRK
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 1:700 N BROAD ST STE LL2
Mailing Address - Street 2:700 NORTH BROAD ST, LL2
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2310
Mailing Address - Country:US
Mailing Address - Phone:908-352-6868
Mailing Address - Fax:908-352-6865
Practice Address - Street 1:700 N BROAD ST STE LL2
Practice Address - Street 2:700 NORTH BROAD ST, LL2
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2310
Practice Address - Country:US
Practice Address - Phone:908-352-6868
Practice Address - Fax:908-352-6865
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00385300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ408717Medicaid