Provider Demographics
NPI:1801807565
Name:CROUCH, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CROUCH
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 1:113 E LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-2209
Mailing Address - Country:US
Mailing Address - Phone:254-386-8149
Mailing Address - Fax:254-386-3494
Practice Address - Street 1:113 E LESLIE ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-2209
Practice Address - Country:US
Practice Address - Phone:254-386-8149
Practice Address - Fax:254-386-3494
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH6139OtherTX LICENSE
TXP087G3171Medicaid
TX1801807565Medicare PIN
TXP087G3171Medicaid