Provider Demographics
NPI:1982675468
Name:MARKS, KENNETH JAY (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAY
Last Name:MARKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 N JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-5513
Mailing Address - Country:US
Mailing Address - Phone:478-445-4817
Mailing Address - Fax:478-445-0963
Practice Address - Street 1:131 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-5513
Practice Address - Country:US
Practice Address - Phone:478-445-4817
Practice Address - Fax:478-445-4817
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0352932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1997OtherMEDICARE ORGANIZATION PTAN
GAGRP2030OtherMEDICARE ORGANIZATION PTAN
GAGRP1997OtherMEDICARE ORGANIZATION PTAN