Provider Demographics
NPI:1881908176
Name:DEZEEUW, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEZEEUW
Suffix:
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 1:3663 BRIARPARK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-5205
Mailing Address - Country:US
Mailing Address - Phone:713-268-3630
Mailing Address - Fax:623-869-3630
Practice Address - Street 1:633 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4517
Practice Address - Country:US
Practice Address - Phone:972-780-1153
Practice Address - Fax:972-298-0931
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist