Provider Demographics
NPI:1326013343
Name:MARK S MOELLER MD PA
Entity Type:Organization
Organization Name:MARK S MOELLER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-661-4670
Mailing Address - Street 1:6300 WEST LOOP SOUTH
Mailing Address - Street 2:STE 680
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401
Mailing Address - Country:US
Mailing Address - Phone:713-661-4670
Mailing Address - Fax:713-661-4672
Practice Address - Street 1:6300 WEST LOOP SOUTH
Practice Address - Street 2:STE 680
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401
Practice Address - Country:US
Practice Address - Phone:713-661-4670
Practice Address - Fax:713-661-4672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2011-10-06
Deactivation Date:2007-12-19
Deactivation Code:
Reactivation Date:2011-10-06
Provider Licenses
StateLicense IDTaxonomies
TXH64432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128313702Medicaid
TX00H59ZMedicare PIN
F24112Medicare UPIN