Provider Demographics
NPI:1609078070
Name:ETTINGER, MARK RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RAYMOND
Last Name:ETTINGER
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 1:4100 INTERNATIONAL PLAZA
Mailing Address - Street 2:600
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4823
Mailing Address - Country:US
Mailing Address - Phone:817-529-1923
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:HOUSE STAFF & GME
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN8184207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP2-0026701OtherINSTITUTIONAL PERMIT