Provider Demographics
NPI:1215033931
Name:GAN, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5746 TROWBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3341
Mailing Address - Country:US
Mailing Address - Phone:915-219-4300
Mailing Address - Fax:915-519-4300
Practice Address - Street 1:3909 N MESA ST STE 100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1501
Practice Address - Country:US
Practice Address - Phone:915-532-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8120207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133738801Medicaid
TX133738808Medicaid
TX89T296OtherBCBS
TX8U4600OtherBCBS
TX89T296Medicare PIN
TX89T296OtherBCBS
A66579Medicare UPIN
TX133738808Medicaid