Basic Information
| Provider Information | |||||||||
| NPI: | 1053381095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRKIN | ||||||||
| FirstName: | GENE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E GUDE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208501341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019337133 | ||||||||
| FaxNumber: | 3019337137 | ||||||||
| Practice Location | |||||||||
| Address1: | 10901 CONNECTICUT AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208951645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019492000 | ||||||||
| FaxNumber: | 3019492002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1071 | MD | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 061368100 | 05 | MD | MEDICAID | 442183301 | 05 | MD | MEDICAID |