Provider Demographics
NPI:1437160934
Name:QUERALT, MARK V (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:V
Last Name:QUERALT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:3724 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE G-10
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1646
Mailing Address - Country:US
Mailing Address - Phone:512-345-5925
Mailing Address - Fax:512-343-7113
Practice Address - Street 1:3724 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE G-10
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1646
Practice Address - Country:US
Practice Address - Phone:512-345-5925
Practice Address - Fax:512-343-7113
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ44562081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036787203Medicaid
TX036787202Medicaid
TX8CV460OtherBCBS
TXTXB132154Medicare PIN
TX8CV460OtherBCBS
TX036787203Medicaid