Provider Demographics
NPI:1275528119
Name:EDEN, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:EDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:EDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:820 REUBEN ST STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4583
Mailing Address - Country:US
Mailing Address - Phone:830-997-9497
Mailing Address - Fax:830-997-5677
Practice Address - Street 1:820 REUBEN ST STE B
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4583
Practice Address - Country:US
Practice Address - Phone:830-997-9497
Practice Address - Fax:830-997-5677
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EH989OtherBCBSTX
TX337166801Medicaid
E10797Medicare UPIN
TX346414Medicare PIN
TX00G11QOtherMEDICARE PTAN
TX0905840001Medicare NSC
TX133364304Medicaid