Provider Demographics
NPI:1437274537
Name:MARK, COREY J (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:J
Last Name:MARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1310 PALUXY RD STE 3000
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5655
Mailing Address - Country:US
Mailing Address - Phone:817-579-3906
Mailing Address - Fax:817-579-3905
Practice Address - Street 1:1310 PALUXY RD STE 3000
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5655
Practice Address - Country:US
Practice Address - Phone:817-579-3906
Practice Address - Fax:817-579-3905
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX752743893207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185888801Medicaid
TX8X8661OtherBCBS
TX185888801Medicaid
TX8J5661Medicare PIN