Provider Demographics
NPI:1700944782
Name:KUTNER, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KUTNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13711 73RD TER
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2303
Mailing Address - Country:US
Mailing Address - Phone:718-575-3510
Mailing Address - Fax:718-575-0391
Practice Address - Street 1:13711 73RD TER
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2303
Practice Address - Country:US
Practice Address - Phone:718-575-3510
Practice Address - Fax:718-575-0391
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008766-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP3098817OtherOXFORD
NYV851XOtherEMPIRE BLUE CROSS
NY01365255Medicaid
NYVK2111Medicare ID - Type UnspecifiedEMPIRE
NY01365255Medicaid