Provider Demographics
NPI:1881155919
Name:BURROUGHS, MARK ALAN JR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:BURROUGHS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 JARVIS ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-7206
Mailing Address - Country:US
Mailing Address - Phone:940-395-4425
Mailing Address - Fax:
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10066630208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery