Provider Demographics
NPI:1588779011
Name:SKELLENGER, MARK EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:SKELLENGER
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 1:445 BAY AREA BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2622
Mailing Address - Country:US
Mailing Address - Phone:281-990-8346
Mailing Address - Fax:281-990-9984
Practice Address - Street 1:445 BAY AREA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2622
Practice Address - Country:US
Practice Address - Phone:281-990-8346
Practice Address - Fax:281-990-9984
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8345B0Medicare PIN
TX8087J0Medicare PIN