Basic Information
| Provider Information | |||||||||
| NPI: | 1154332088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASANOVA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148209248 | ||||||||
| FaxNumber: | 2148209458 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148209248 | ||||||||
| FaxNumber: | 2148209458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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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 | 207R00000X | L6008 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | L6008 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 158443501 | 05 | TX | MEDICAID | 8G0891 | 01 | TX | BCBS | OTHER | 158443502 | 05 | TX | MEDICAID |