Provider Demographics
NPI:1154650877
Name:BARRY, MARK RICHARD (DMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:BARRY
Suffix:
Gender:M
Credentials:DMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591958
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0147
Mailing Address - Country:US
Mailing Address - Phone:210-219-4524
Mailing Address - Fax:
Practice Address - Street 1:1202 EVANS RD APT 1736
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-6974
Practice Address - Country:US
Practice Address - Phone:210-219-4524
Practice Address - Fax:210-219-4524
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40373183500000X
MADN21100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No122300000XDental ProvidersDentist