Provider Demographics
NPI:1811997042
Name:KWALBRUN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KWALBRUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9304
Mailing Address - Country:US
Mailing Address - Phone:315-786-5046
Mailing Address - Fax:315-786-5043
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9304
Practice Address - Country:US
Practice Address - Phone:315-786-5000
Practice Address - Fax:315-786-5001
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2257262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461787Medicaid
NY02461787Medicaid
NYI01576Medicare UPIN