Provider Demographics
NPI:1508923194
Name:KRZYSTON, MARK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:KRZYSTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:STE 225
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-534-8723
Mailing Address - Fax:803-536-0030
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:STE 225
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-534-8723
Practice Address - Fax:803-536-0030
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2015-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SCSC12677207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4003Medicaid
SC7386Medicare PIN
SCB914741857Medicare UPIN