Provider Demographics
NPI:1376844456
Name:MARK A. BISHARA, MD, PA
Entity Type:Organization
Organization Name:MARK A. BISHARA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BISHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:817-477-9000
Mailing Address - Street 1:550 N WALNUT CREEK DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3223
Mailing Address - Country:US
Mailing Address - Phone:817-477-9000
Mailing Address - Fax:817-887-5924
Practice Address - Street 1:550 N WALNUT CREEK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3223
Practice Address - Country:US
Practice Address - Phone:817-477-9000
Practice Address - Fax:817-887-5924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236064174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty