Provider Demographics
NPI:1134120256
Name:ELDORE, MARK L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:ELDORE
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 1:824 SOUTHPARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75752
Mailing Address - Country:US
Mailing Address - Phone:903-675-7376
Mailing Address - Fax:903-677-4234
Practice Address - Street 1:824 SOUTHPARK CIRCLE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75752
Practice Address - Country:US
Practice Address - Phone:903-675-7376
Practice Address - Fax:903-677-4234
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0461207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S2730OtherBCBS PROVIDER NUMBER
TX178423301Medicaid
TX048064207Medicaid
TXG98341Medicare UPIN
TX048064207Medicaid