Basic Information
| Provider Information | |||||||||
| NPI: | 1477949873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVERIDGE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | STOCKTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144566393 | ||||||||
| FaxNumber: | 2144567232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159362555 | ||||||||
| FaxNumber: | 6159362419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LH0002X | R7172 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine | 2080H0002X | R7172 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine | 208000000X | R7172 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 391078803 | 05 | TX | MEDICAID |