Provider Demographics
NPI:1982890299
Name:KANE, MARK JOSEPH (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:KANE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 482 BOX 2948
Mailing Address - Street 2:FPO AP
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 2948
Practice Address - Street 2:FPO AP
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362
Practice Address - Country:JP
Practice Address - Phone:0904-470-0463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
7737OtherIDC