Provider Demographics
NPI:1699728840
Name:SCROGGINS, MARK EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SCROGGINS
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 1:2612 HARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-8308
Mailing Address - Country:US
Mailing Address - Phone:817-283-8366
Mailing Address - Fax:817-283-8466
Practice Address - Street 1:2612 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-8308
Practice Address - Country:US
Practice Address - Phone:817-283-8366
Practice Address - Fax:817-283-8466
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8892207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032536701Medicaid
TXB26292Medicare UPIN
TX00CM44Medicare ID - Type UnspecifiedMEICARE