Provider Demographics
NPI:1942296405
Name:KINGSTON, MARK B JR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:KINGSTON
Suffix:JR
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 1:203 S WATER ST
Mailing Address - Street 2:PO BOX 120
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1387
Mailing Address - Country:US
Mailing Address - Phone:606-638-4504
Mailing Address - Fax:606-638-4186
Practice Address - Street 1:203 S WATER ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1387
Practice Address - Country:US
Practice Address - Phone:606-638-4504
Practice Address - Fax:606-638-4186
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20555208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64205552Medicaid
WV0049452000Medicaid
C67981Medicare UPIN
KY1136001Medicare ID - Type Unspecified