Provider Demographics
NPI:1417283003
Name:KITZ, MARK RICHARD (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:KITZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WALLACE BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-2578
Mailing Address - Country:US
Mailing Address - Phone:856-829-0015
Mailing Address - Fax:856-829-0043
Practice Address - Street 1:2200 WALLACE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-2578
Practice Address - Country:US
Practice Address - Phone:856-829-0015
Practice Address - Fax:856-829-0043
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01335400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist