Provider Demographics
NPI:1346687738
Name:PEDERSEN, MARK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:PEDERSEN
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5939 HARRY HINES BLVD PROFESSIONAL BUILDING 2 SUITE 700
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-2612
Practice Address - Country:US
Practice Address - Phone:214-645-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-27
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8601207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology