Provider Demographics
NPI:1659341055
Name:BARRET, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:BARRET
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3978208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5152004OtherAETNA
TXTAX ID AND 027OtherTRICARE
TX122991OtherSUPERIOR/CHIPS
TX83Y676OtherBCBS
TX136283211Medicaid
TX8DC103OtherBCBS
TX136283212Medicaid
TX752616977118OtherTRICARE
TX136283208Medicaid
TX5152004OtherAETNA
TX83Y676Medicare PIN
TX8DC103OtherBCBS
TX122991OtherSUPERIOR/CHIPS