Provider Demographics
NPI:1770544389
Name:SANDERS, MARK ALLEN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2718
Mailing Address - Country:US
Mailing Address - Phone:817-688-1588
Mailing Address - Fax:817-423-7361
Practice Address - Street 1:3437 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2718
Practice Address - Country:US
Practice Address - Phone:817-688-1588
Practice Address - Fax:817-423-7361
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9653207QG0300X, 207Q00000X, 209800000X
TXK8653207QH0002X
IL036.131054207Q00000X, 207QG0300X, 207QH0002X, 209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151887001Medicaid
TX151887004Medicaid
TX151887003Medicaid
TX080186304OtherRAILROAD MEDICARE PIN
TX8B2215OtherBCBS
TX151887004Medicaid
TX8539B7Medicare PIN
TX151887003Medicaid