Provider Demographics
NPI:1063980670
Name:MATHIS, MARK JR (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MATHIS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:611 N MACARTHUR BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-7467
Mailing Address - Country:US
Mailing Address - Phone:972-253-9355
Mailing Address - Fax:972-253-9357
Practice Address - Street 1:611 N MACARTHUR BLVD STE 110
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-7467
Practice Address - Country:US
Practice Address - Phone:972-253-9355
Practice Address - Fax:972-253-9357
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13943OtherCHIROPRACTIC LICENSE