Provider Demographics
NPI:1942519319
Name:GAJJAR, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GAJJAR
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 1:1180 SETON PKWY STE 450
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6178
Mailing Address - Country:US
Mailing Address - Phone:512-504-0860
Mailing Address - Fax:512-504-0861
Practice Address - Street 1:1180 SETON PKWY STE 450
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6178
Practice Address - Country:US
Practice Address - Phone:512-504-0860
Practice Address - Fax:512-504-0861
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058132207R00000X
TXR9755207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease