Basic Information
Provider Information | |||||||||
NPI: | 1205941192 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIRKIN FOOT ASSOCIATES PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2415 MUSGROVE RD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209045200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013846500 | ||||||||
FaxNumber: | 3013846670 | ||||||||
Practice Location | |||||||||
Address1: | 10901 CONNECTICUT AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | KENSINGTON | ||||||||
State: | MD | ||||||||
PostalCode: | 208951645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019492000 | ||||||||
FaxNumber: | 3019492002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 11/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIRKIN | ||||||||
AuthorizedOfficialFirstName: | GENE | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3019492000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X |   | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 061368100 | 05 | MD |   | MEDICAID |