Provider Demographics
NPI:1407027105
Name:MRJ MD PA
Entity Type:Organization
Organization Name:MRJ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-276-0039
Mailing Address - Street 1:5744 LBJ FWY
Mailing Address - Street 2:SUITE180
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6322
Mailing Address - Country:US
Mailing Address - Phone:214-276-0039
Mailing Address - Fax:469-484-4076
Practice Address - Street 1:5744 LBJ FWY
Practice Address - Street 2:SUITE 180
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6322
Practice Address - Country:US
Practice Address - Phone:214-276-0039
Practice Address - Fax:469-484-4076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164971701Medicaid
TX00603VMedicare PIN
TXG07158Medicare UPIN