Provider Demographics
NPI:1881652238
Name:KENYON, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:KENYON
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 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0220
Mailing Address - Fax:716-323-0293
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-0220
Practice Address - Fax:716-323-0293
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228634208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1292497OtherIHA
040426003098OtherFIDELIS
PA100831371001Medicaid
00026380601OtherUNIVERA
000527294001OtherBC/BS
NY02409052Medicaid
000527294001OtherBC/BS
H85501Medicare UPIN