Basic Information
| Provider Information | |||||||||
| NPI: | 1386622827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GABBIE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2900 SAINT MICHAEL DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145383 | ||||||||
| FaxNumber: | 9036145343 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755030705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C7084 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | H5885 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1G1604 | 01 | TX | MEDICARE | OTHER | 8M7710 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 113032001 | 05 | AR | MEDICAID | P02599443 | 01 | TX | RR MCR | OTHER | 100072350A | 05 | OK | MEDICAID | 127992908 | 05 | TX | MEDICAID | 50271 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER |