Provider Demographics
NPI:1407866403
Name:MARK, STEPHEN L (M D)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:MARK
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 LONDONDERRY DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7921
Mailing Address - Country:US
Mailing Address - Phone:254-772-6770
Mailing Address - Fax:254-772-8471
Practice Address - Street 1:405 LONDONDERRY DR STE 202
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7921
Practice Address - Country:US
Practice Address - Phone:254-772-6770
Practice Address - Fax:254-772-8471
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE27032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R970OtherBLUE CROSS BLUE SHIELD
TX00R970Medicare ID - Type Unspecified
TX00R970OtherBLUE CROSS BLUE SHIELD