Provider Demographics
NPI:1255384392
Name:CWIKLA, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:CWIKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 STATE HIGHWAY 161
Mailing Address - Street 2:STE 160
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2816
Mailing Address - Country:US
Mailing Address - Phone:972-259-4768
Mailing Address - Fax:972-254-9640
Practice Address - Street 1:7301 STATE HIGHWAY 161
Practice Address - Street 2:STE 160
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2816
Practice Address - Country:US
Practice Address - Phone:972-259-4768
Practice Address - Fax:972-254-9640
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3878174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114457802Medicaid
TXB22087Medicare UPIN
TXOA6174Medicare PIN
TXOA3689Medicare PIN