Provider Demographics
NPI:1174598619
Name:KROLL, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:KROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 IRON BRIDGE RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5304
Mailing Address - Country:US
Mailing Address - Phone:732-780-0100
Mailing Address - Fax:732-780-8452
Practice Address - Street 1:501 IRON BRIDGE RD
Practice Address - Street 2:SUITE 15
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-5304
Practice Address - Country:US
Practice Address - Phone:732-780-0100
Practice Address - Fax:732-780-8452
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA32880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
222981046OtherBLUE CROSS/BLUE SHIELD
33340OtherAETNA
NJ3408302Medicaid
NJ108951Medicare PIN