Provider Demographics
NPI:1457351066
Name:RACE, MARK CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:RACE
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 1:203 NACOGDOCHES ST
Mailing Address - Street 2:STE 350
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2462
Mailing Address - Country:US
Mailing Address - Phone:903-586-6841
Mailing Address - Fax:903-586-7792
Practice Address - Street 1:203 NACOGDOCHES ST
Practice Address - Street 2:STE 350
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2462
Practice Address - Country:US
Practice Address - Phone:903-586-6841
Practice Address - Fax:903-586-7792
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3714208100000X
AL00019671208100000X
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
C20764Medicare UPIN
TX00GS37Medicare ID - Type Unspecified