Provider Demographics
NPI:1932142361
Name:HULSEY, MARK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:HULSEY
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 1:1701 RENAISSANCE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3084
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:058-440-0562
Practice Address - Street 1:1701 RENAISSANCE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3084
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2330207RR0500X
OK17394207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147171601Medicaid
TX85584KMedicare ID - Type Unspecified
TX147171601Medicaid