Provider Demographics
NPI:1679580435
Name:DAVIS, MARK D (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:6500 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4136
Practice Address - Country:US
Practice Address - Phone:817-263-2600
Practice Address - Fax:817-263-2805
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004142363A00000X
TXPA06442363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208650601Medicaid
MA110F335760OtherBCBSM
TX208650601Medicaid
MA110F335760OtherBCBSM
MAON91420004Medicare ID - Type Unspecified