Basic Information
| Provider Information | |||||||||
| NPI: | 1679653919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6621 FANNIN ST., MC A1170 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328241177 | ||||||||
| FaxNumber: | 8328251187 | ||||||||
| Practice Location | |||||||||
| Address1: | 6621 FANNIN ST, MC A1170 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328241177 | ||||||||
| FaxNumber: | 8328251187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 12/23/2011 | ||||||||
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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 | 2080P0204X | G0258 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 134038201 | 05 | TX | MEDICAID |