Provider Demographics
NPI:1003085507
Name:TY, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:TY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CITY WEST BLVD.
Mailing Address - Street 2:775
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042
Mailing Address - Country:US
Mailing Address - Phone:713-779-8963
Mailing Address - Fax:713-774-4600
Practice Address - Street 1:2500 CITY WEST BLVD.
Practice Address - Street 2:775
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042
Practice Address - Country:US
Practice Address - Phone:713-779-8963
Practice Address - Fax:713-774-4600
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC22862Medicare UPIN