Provider Demographics
NPI:1417168345
Name:DAMMERT, MARK O (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:DAMMERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1180 SETON PKWY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6178
Mailing Address - Country:US
Mailing Address - Phone:512-268-5282
Mailing Address - Fax:512-268-5769
Practice Address - Street 1:1180 SETON PKWY
Practice Address - Street 2:SUITE 420
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6178
Practice Address - Country:US
Practice Address - Phone:512-268-5282
Practice Address - Fax:512-268-5769
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2014-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXN9533207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288309203Medicaid
TX288309202Medicaid
TX8DY645OtherBCBS
TX288309203Medicaid
TX317552YVKLMedicare PIN