Provider Demographics
NPI:1053381095
Name:MIRKIN, GENE S (DPM)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:S
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E GUDE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1341
Mailing Address - Country:US
Mailing Address - Phone:301-933-7133
Mailing Address - Fax:301-933-7137
Practice Address - Street 1:10901 CONNECTICUT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1645
Practice Address - Country:US
Practice Address - Phone:301-949-2000
Practice Address - Fax:301-949-2002
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1071213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD061368100Medicaid
MD442183301Medicaid
U24310Medicare UPIN
MD442183301Medicaid
MD061368100Medicaid
DC0863510001Medicare NSC
DC250722YFCTMedicare PIN
DC613747M38Medicare PIN