Provider Demographics
NPI:1790781748
Name:KANE, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:KANE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2784
Practice Address - Fax:860-679-4126
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2022-09-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT0380102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1380104Medicaid
CT1380104Medicaid
CT300002671Medicare PIN