Provider Demographics
NPI:1952372542
Name:MIRKIN, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR STE 308
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1739
Mailing Address - Country:US
Mailing Address - Phone:703-698-8960
Mailing Address - Fax:703-716-8703
Practice Address - Street 1:3028 JAVIER RD STE 500
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-698-8960
Practice Address - Fax:571-494-5794
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101036056207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
187598OtherANTHEM BCBS
79160004OtherCAREFIRST BCBS
231620OtherANTHEM BCBS
336682OtherANTHEM BCBS
VA6096026Medicaid
VA100010309OtherRAILROAD MEDICARE
178732OtherANTHEM BCBS
341902OtherANTHEM BCBS
740013OtherANTHEM BCBS
79160004OtherCAREFIRST BCBS
VA100010309OtherRAILROAD MEDICARE