Provider Demographics
NPI:1295726784
Name:EIDSON, MARK CARROLL (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CARROLL
Last Name:EIDSON
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 1:710 E ANDERSON ST
Mailing Address - Street 2:STE C
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5870
Mailing Address - Country:US
Mailing Address - Phone:817-599-9472
Mailing Address - Fax:817-458-0209
Practice Address - Street 1:710 E ANDERSON ST
Practice Address - Street 2:STE C
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5870
Practice Address - Country:US
Practice Address - Phone:817-599-9472
Practice Address - Fax:817-458-0209
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110474702Medicaid
B22480Medicare UPIN
TX00SF58Medicare ID - Type Unspecified