Provider Demographics
NPI:1558364406
Name:IRVIN, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:IRVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1194
Mailing Address - Country:US
Mailing Address - Phone:270-247-8100
Mailing Address - Fax:270-247-7780
Practice Address - Street 1:1111 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1194
Practice Address - Country:US
Practice Address - Phone:270-247-8100
Practice Address - Fax:270-247-7780
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64280308Medicaid
KY1317605Medicare PIN
KY64280308Medicaid