Provider Demographics
NPI:1720055833
Name:KOONE, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:KOONE
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 1:815 PECAN GROVE RD E
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-1768
Mailing Address - Country:US
Mailing Address - Phone:903-892-2126
Mailing Address - Fax:903-892-2129
Practice Address - Street 1:815 E PECAN GROVE RD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1768
Practice Address - Country:US
Practice Address - Phone:903-892-2126
Practice Address - Fax:903-892-2129
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1976207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103628701Medicaid
TX103628701Medicaid
TXD92881Medicare UPIN