Basic Information
| Provider Information | |||||||||
| NPI: | 1013963172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | PRESLEY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8440 WALNUT HILL LN | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143451494 | ||||||||
| FaxNumber: | 2143451452 | ||||||||
| Practice Location | |||||||||
| Address1: | 8440 WALNUT HILL LN | ||||||||
| Address2: | STE 500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143451491 | ||||||||
| FaxNumber: | 2143455708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | H2615 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 125805502 | 05 | TX | MEDICAID | 040007318 | 01 | TX | RAILROAD MEDICARE | OTHER |