Provider Demographics
NPI:1831743939
Name:URIDEL, MARK (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:URIDEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W WILLIAM CANNON DR STE 409
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5290
Mailing Address - Country:US
Mailing Address - Phone:512-852-8434
Mailing Address - Fax:512-852-8435
Practice Address - Street 1:2500 W WILLIAM CANNON DR STE 409
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5290
Practice Address - Country:US
Practice Address - Phone:512-852-8434
Practice Address - Fax:512-852-8435
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1121085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist