Provider Demographics
NPI:1477967404
Name:EDGCOMB, MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:EDGCOMB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST STE 1404
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2706
Mailing Address - Country:US
Mailing Address - Phone:713-790-0600
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST STE 1404
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2706
Practice Address - Country:US
Practice Address - Phone:713-790-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065469208600000X
CODR.0058405208600000X
TXS5605208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery