Provider Demographics
NPI:1679517528
Name:SOWELL, MARK EPHROM (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EPHROM
Last Name:SOWELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3316 N UNIVERSITY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2632
Mailing Address - Country:US
Mailing Address - Phone:936-559-1700
Mailing Address - Fax:936-559-1713
Practice Address - Street 1:3316 N UNIVERSITY DR
Practice Address - Street 2:SUITE C
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2632
Practice Address - Country:US
Practice Address - Phone:936-559-1700
Practice Address - Fax:936-559-1713
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1449213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018599301Medicaid
TX480029919OtherMEDICARE RAILROAD
TX0096DSOtherBLUE CROSS/BLUE SHIELD
TX4560260001OtherPALMETTO DMERC
TX0096DSOtherBLUE CROSS/BLUE SHIELD