Provider Demographics
NPI:1992004006
Name:KIRSCHENBAUM, MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KIRSCHENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-1094
Mailing Address - Country:US
Mailing Address - Phone:718-438-4400
Mailing Address - Fax:
Practice Address - Street 1:4406 12TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-1094
Practice Address - Country:US
Practice Address - Phone:718-438-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY273521207Q00000X
NY273521-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty