Provider Demographics
NPI:1306884333
Name:WALBERG, MARK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:WALBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:3410 WORTH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2003
Practice Address - Country:US
Practice Address - Phone:214-370-1000
Practice Address - Fax:214-370-1026
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6272207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116591205Medicaid
TX8R1578OtherBLUE CROSS OF TEXAS
TX116591201Medicaid
TX116591206OtherCSHCN
TX116591207Medicaid
TX8111N1Medicare PIN
TX8R1578OtherBLUE CROSS OF TEXAS
TX116591201Medicaid
TX116591206OtherCSHCN
TX900003369Medicare PIN
TX80799KMedicare PIN
TX8A9595Medicare PIN
TX8799M4Medicare PIN
TXF78524Medicare UPIN