Provider Demographics
NPI:1578564316
Name:KIRCHBLUM, MARK JAY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAY
Last Name:KIRCHBLUM
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 1:2000 N VILLAGE AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ROCKVILLE CTR
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1078
Mailing Address - Country:US
Mailing Address - Phone:516-764-1303
Mailing Address - Fax:516-764-3618
Practice Address - Street 1:2000 N VILLAGE AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:ROCKVILLE CTR
Practice Address - State:NY
Practice Address - Zip Code:11570-1078
Practice Address - Country:US
Practice Address - Phone:516-764-1303
Practice Address - Fax:516-764-3618
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125940207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113042516Medicare PIN
B12293Medicare UPIN