Basic Information
| Provider Information | |||||||||
| NPI: | 1447372230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16811 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16811 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301089527 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | M9069 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 202106508 | 05 | TX | MEDICAID | 202106509 | 05 | TX | MEDICAID | 2021065-02 | 05 | TX | MEDICAID |