Provider Demographics
NPI:1619081932
Name:CASSIDY, MARK MCCREARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MCCREARY
Last Name:CASSIDY
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 1:1430 TULANE AVE
Mailing Address - Street 2:SL-48
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-5152
Mailing Address - Fax:504-988-4237
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-5152
Practice Address - Fax:504-988-4237
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016062207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1328987Medicaid
LA53180Medicare PIN
LA1328987Medicaid