Provider Demographics
NPI:1508001900
Name:MARK, KEVIN GEORGE (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:GEORGE
Last Name:MARK
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 1:5936 HARTER RD
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9623
Mailing Address - Country:US
Mailing Address - Phone:585-335-8284
Mailing Address - Fax:
Practice Address - Street 1:5936 HARTER RD
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9623
Practice Address - Country:US
Practice Address - Phone:585-335-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2008-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007508-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist