Provider Demographics
NPI:1568690279
Name:WEISBERG, MARK JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JORDAN
Last Name:WEISBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO VIEJO
Mailing Address - State:TX
Mailing Address - Zip Code:78575-9629
Mailing Address - Country:US
Mailing Address - Phone:956-518-1016
Mailing Address - Fax:
Practice Address - Street 1:100 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3328
Practice Address - Country:US
Practice Address - Phone:956-518-1016
Practice Address - Fax:956-372-1717
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177525601Medicaid