Provider Demographics
NPI:1508860263
Name:IRWIN, MARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:IRWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3701
Mailing Address - Country:US
Mailing Address - Phone:646-460-1479
Mailing Address - Fax:718-875-7864
Practice Address - Street 1:359 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-3701
Practice Address - Country:US
Practice Address - Phone:646-460-1479
Practice Address - Fax:718-875-7864
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1685650208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01128523Medicaid
A61496Medicare UPIN
NY24E411Medicare PIN