Provider Demographics
NPI:1902919459
Name:STORY, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:STORY
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 1:601 W STATE HIGHWAY 6
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5575
Mailing Address - Country:US
Mailing Address - Phone:254-741-6113
Mailing Address - Fax:254-741-6629
Practice Address - Street 1:601 W STATE HIGHWAY 6
Practice Address - Street 2:SUITE 105
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5575
Practice Address - Country:US
Practice Address - Phone:254-741-6113
Practice Address - Fax:254-741-6629
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8944208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098339702Medicaid
TXC22326Medicare UPIN
TX88K691Medicare ID - Type Unspecified