Provider Demographics
NPI:1891882270
Name:DE ANDA, MARK ANTHONY (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:DE ANDA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2322 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3237
Mailing Address - Country:US
Mailing Address - Phone:210-314-6725
Mailing Address - Fax:210-957-8585
Practice Address - Street 1:2322 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-314-6725
Practice Address - Fax:210-957-8585
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1170429208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308673802Medicaid