Provider Demographics
NPI:1568672996
Name:HAVERKORN, MARK E (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:HAVERKORN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 N LOOP 1604 E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-5463
Mailing Address - Country:US
Mailing Address - Phone:210-778-0002
Mailing Address - Fax:
Practice Address - Street 1:5418 N LOOP 1604 E
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-5463
Practice Address - Country:US
Practice Address - Phone:210-778-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4460204E00000X
TX237391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05982Medicaid