Provider Demographics
NPI:1346289055
Name:ANDERSON, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0423207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130578109Medicaid
TX75-0818167-048OtherTRICARE
TX8L1047OtherBCBS
TX750818167-044OtherTRICARE
TX015OtherTRICARE
TXP01464103OtherRAIL ROAD MEDICARE
TX130578103Medicaid
TX75-2616977-001OtherTRICARE
TX75-2616977-028OtherTRICARE
TX8DQ330OtherBCBS
TX750818167022OtherTRICARE
TX990014514OtherRAIL ROAD
TX005OtherTRICARE
TX130578110Medicaid
TX75-2616977-002OtherTRICARE
TX8EX117OtherBCBS
TX0061EKOtherBCBS
TX130578107Medicaid
TX130578108Medicaid
TX130578103Medicaid
TX990014514OtherRAIL ROAD
TX015OtherTRICARE
TX270645YMAFMedicare PIN
TX270645YNSXMedicare Oscar/Certification
TX930092925Medicare PIN