Provider Demographics
NPI:1922041599
Name:BUSSELL, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:BUSSELL
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 1:6901 RIVER PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8465
Mailing Address - Country:US
Mailing Address - Phone:817-732-0800
Mailing Address - Fax:817-956-9119
Practice Address - Street 1:6116 OAKBEND TRAIL
Practice Address - Street 2:112
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3926
Practice Address - Country:US
Practice Address - Phone:817-346-7800
Practice Address - Fax:817-346-7408
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0452208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153003202Medicaid
TX84Y321Medicare PIN
TX00T08WMedicare PIN
TX153003202Medicaid