Basic Information
| Provider Information | |||||||||
| NPI: | 1477563898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4604 NE STALLINGS DR | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759651608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365598770 | ||||||||
| FaxNumber: | 9365598773 | ||||||||
| Practice Location | |||||||||
| Address1: | 4604 NE STALLINGS DR | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759651608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365598770 | ||||||||
| FaxNumber: | 9365598773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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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 | 207Q00000X | J8492 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 135176908 | 05 | TX | MEDICAID | 135176907 | 05 | TX | MEDICAID |