Provider Demographics
NPI:1477669992
Name:THIEBERG, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:THIEBERG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4708 ALLIANCE BLVD STE 300
Mailing Address - Street 2:BAYLOR MEDICAL PLAZA 1
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5339
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD STE 300
Practice Address - Street 2:BAYLOR MEDICAL PLAZA 1
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5339
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ7227207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83X005OtherBCBS
TX104001602Medicaid
TX8L4077Medicare PIN
TX83X005OtherBCBS
TX104001602Medicaid
TX070007318Medicare PIN
TX83X005Medicare PIN