Provider Demographics
NPI:1437151842
Name:MAXWELL, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 PINE ST
Mailing Address - Street 2:STE A
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2431
Mailing Address - Country:US
Mailing Address - Phone:325-674-9494
Mailing Address - Fax:325-674-9493
Practice Address - Street 1:1933 PINE ST
Practice Address - Street 2:STE A
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2431
Practice Address - Country:US
Practice Address - Phone:325-674-9494
Practice Address - Fax:325-674-9493
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9751207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036031501Medicaid
TX75261819179601OtherTRICARE
TX118796100OtherFIRST CARE
TX036031501Medicaid
TXG17208Medicare UPIN