Provider Demographics
NPI:1851393896
Name:COYNE, MARK XAVIER (MD PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:XAVIER
Last Name:COYNE
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:186 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4305
Mailing Address - Country:US
Mailing Address - Phone:301-695-6466
Mailing Address - Fax:301-695-1094
Practice Address - Street 1:186 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4305
Practice Address - Country:US
Practice Address - Phone:301-695-6466
Practice Address - Fax:301-695-1094
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029521208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD334631500Medicaid
MD826M440FMedicare PIN
MDD77957Medicare UPIN