Provider Demographics
NPI:1417960550
Name:PIDALA, MARK J (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:PIDALA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 2307
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-486-4600
Mailing Address - Fax:713-790-9251
Practice Address - Street 1:800 PEAKWOOD DR
Practice Address - Street 2:SUITE 2C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090
Practice Address - Country:US
Practice Address - Phone:713-486-4650
Practice Address - Fax:281-440-0759
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2018-06-01
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Provider Licenses
StateLicense IDTaxonomies
TXK6239208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037009002Medicaid
TX80291KMedicare PIN