Provider Demographics
NPI:1447473319
Name:MARK A. MARCONI, D.O., P.A.
Entity type:Organization
Organization Name:MARK A. MARCONI, D.O., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARCONI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:979-532-1159
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-1128
Mailing Address - Country:US
Mailing Address - Phone:979-532-1159
Mailing Address - Fax:979-532-2119
Practice Address - Street 1:10119 US 59 HWY
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-7224
Practice Address - Country:US
Practice Address - Phone:979-532-1159
Practice Address - Fax:979-532-2119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158638001Medicaid
TX158638001Medicaid