Provider Demographics
NPI:1891090221
Name:MARK A. ISAEFF, MD PA
Entity Type:Organization
Organization Name:MARK A. ISAEFF, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ISAEFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-572-4431
Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:542
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5609
Mailing Address - Country:US
Mailing Address - Phone:210-572-4431
Mailing Address - Fax:210-572-4435
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:542
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-572-4431
Practice Address - Fax:210-572-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-16
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218930001Medicaid
TXTXB118188Medicare PIN