Basic Information
| Provider Information | |||||||||
| NPI: | 1639259039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAFFET | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16811 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16811 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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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 | 207X00000X | H7633 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | H7633 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 128829209 | 05 | TX | MEDICAID | 128829210 | 05 | TX | MEDICAID | 610119705 BROOKS | 01 | TX | US DEPT OF LABOR | OTHER | 128829211 | 05 | TX | MEDICAID | 1639259039 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | PENDING | 05 | TX | MEDICAID | P00894860 | 01 | TX | RR MEDICARE | OTHER | P00916187 | 01 | TX | MEDICARE RR | OTHER | P01089605 | 01 | TX | RR MEDICARE | OTHER | 128829212 | 05 | TX | MEDICAID | 128829213 | 05 | TX | MEDICAID | 128829208 | 05 | TX | MEDICAID | 610119701 | 01 | TX | US DEPT OF LABOR | OTHER |