MEDICARE: DR. MARK DOUGLAS PUCEK 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	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician	G3707	TX

General Provider Information

NPI Number	:	1720018708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DOUGLAS PUCEK M.D.

Provider Business Mailing Address
First Line	:	912 AVENUE J
Second Line	:
City	:	DICKINSON
State	:	TX
Zip	:	77539-5294
Country	:	US
Telephone Number	:	281-337-8010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 SOUTH LOOP W
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-3825
Country	:	US
Telephone Number	:	713-797-6106
Fax Number	:	713-790-0507

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	07/08/2007

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