Provider Demographics
NPI:1295700227
Name:HEAVER, MARK ALBERT (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALBERT
Last Name:HEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 S BUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-6907
Mailing Address - Country:US
Mailing Address - Phone:214-381-1187
Mailing Address - Fax:214-381-7213
Practice Address - Street 1:2942 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6907
Practice Address - Country:US
Practice Address - Phone:214-381-1187
Practice Address - Fax:214-381-7213
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK81Medicare ID - Type Unspecified
TXD97391Medicare UPIN