Provider Demographics
NPI:1649301037
Name:MARK MCDONNELL DPM PA
Entity type:Organization
Organization Name:MARK MCDONNELL DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-353-8661
Mailing Address - Street 1:1305 WONDER WORLD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7546
Mailing Address - Country:US
Mailing Address - Phone:512-353-8661
Mailing Address - Fax:512-353-8355
Practice Address - Street 1:1305 WONDER WORLD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7546
Practice Address - Country:US
Practice Address - Phone:512-353-8661
Practice Address - Fax:512-353-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1440213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81483Medicare UPIN