Provider Demographics
NPI:1265407761
Name:HUPERT, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:HUPERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1125 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4514
Mailing Address - Country:US
Mailing Address - Phone:817-348-0821
Mailing Address - Fax:817-348-0073
Practice Address - Street 1:1124 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4557
Practice Address - Country:US
Practice Address - Phone:817-348-0821
Practice Address - Fax:817-348-0073
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1619207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00289085OtherMEDICARE RAILROAD
TX146391102Medicaid
TX8J8302OtherBCBS
TX8J8302OtherBCBS
752712328OtherTAX ID NUMBER
P00289085OtherMEDICARE RAILROAD