Provider Demographics
NPI:1104815075
Name:ISAEFF, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ISAEFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 542
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5607
Mailing Address - Country:US
Mailing Address - Phone:210-572-4431
Mailing Address - Fax:210-572-4435
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 542
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5607
Practice Address - Country:US
Practice Address - Phone:210-572-4431
Practice Address - Fax:210-572-4435
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK8638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110241471OtherRAILROAD MEDICARE
TX144897204Medicaid
TX144867202Medicaid
TX00748FMedicare PIN
TXTXB118189Medicare PIN
TX144867202Medicaid