MEDICARE: MARK V. QUERALT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	J4456	TX
2	208100000X	Physical Medicine & Rehabilitation Physician	J4456	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8CV460	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1437160934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK V. QUERALT M.D.

Provider Business Mailing Address
First Line	:	3724 EXECUTIVE CENTER DR
Second Line	:	SUITE G-10
City	:	AUSTIN
State	:	TX
Zip	:	78731-1646
Country	:	US
Telephone Number	:	512-345-5925
Fax Number	:	512-343-7113

Provider Business Practice Location Address
First Line	:	3724 EXECUTIVE CENTER DR
Second Line	:	SUITE G-10
City	:	AUSTIN
State	:	TX
Zip	:	78731-1646
Country	:	US
Telephone Number	:	512-345-5925
Fax Number	:	512-343-7113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	01/23/2013

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Directions to “ MARK V. QUERALT M.D.” Practice Location

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