Provider Demographics
NPI:1417954124
Name:HARRISON, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:HARRISON
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 1:620 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-4906
Mailing Address - Country:US
Mailing Address - Phone:956-682-9680
Mailing Address - Fax:956-682-9915
Practice Address - Street 1:620 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-4906
Practice Address - Country:US
Practice Address - Phone:956-682-9680
Practice Address - Fax:956-682-9915
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG45982085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX96320902Medicaid
TX96320902Medicaid
TXB62621Medicare UPIN