Provider Demographics
NPI:1194839290
Name:BICKLEY, MARK SHANE (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SHANE
Last Name:BICKLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2900 DENTON HWY STE A
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117-3763
Mailing Address - Country:US
Mailing Address - Phone:817-831-2012
Mailing Address - Fax:817-831-0134
Practice Address - Street 1:2900 DENTON HWY STE A
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3763
Practice Address - Country:US
Practice Address - Phone:817-831-2012
Practice Address - Fax:817-831-0134
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6051207Q00000X
HI1671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine