Provider Demographics
NPI:1790756708
Name:POAG, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:POAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12554 RIATA VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6431
Mailing Address - Country:US
Mailing Address - Phone:512-795-5100
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG54892085R0202X
MI43010562122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039376102Medicaid
MI2794238Medicaid
MI2794238Medicaid