Basic Information
| Provider Information | |||||||||
| NPI: | 1437160934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUERALT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3724 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE G-10 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123455925 | ||||||||
| FaxNumber: | 5123437113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3724 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE G-10 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123455925 | ||||||||
| FaxNumber: | 5123437113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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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 | 2081P2900X | J4456 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | J4456 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036787203 | 05 | TX | MEDICAID | 036787202 | 05 | TX | MEDICAID | 8CV460 | 01 | TX | BCBS | OTHER |