Provider Demographics
NPI:1205905494
Name:CAPISTRANO, C MARK (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:MARK
Last Name:CAPISTRANO
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 1:3201 UNIVERSITY DR E
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3475
Mailing Address - Country:US
Mailing Address - Phone:979-731-8558
Mailing Address - Fax:979-731-8654
Practice Address - Street 1:3201 UNIVERSITY DR E
Practice Address - Street 2:SUITE 250
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3475
Practice Address - Country:US
Practice Address - Phone:979-731-8558
Practice Address - Fax:979-731-8654
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8943207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V4920OtherBLUE CROSS BLUE SHIELD
TX8V4920OtherBLUE CROSS BLUE SHIELD
TX8G1461Medicare ID - Type Unspecified