Provider Demographics
NPI:1043229123
Name:FUGIT, MARK H (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:FUGIT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17110 NORTH DALLAS PARKWAY
Mailing Address - Street 2:SUITE 222
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1915
Mailing Address - Country:US
Mailing Address - Phone:972-267-2642
Mailing Address - Fax:972-267-2586
Practice Address - Street 1:17110 NORTH DALLAS PARKWAY
Practice Address - Street 2:SUITE 222
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1915
Practice Address - Country:US
Practice Address - Phone:972-267-2642
Practice Address - Fax:972-267-2586
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0352759Medicaid
TX0352759Medicaid