Provider Demographics
NPI:1114315629
Name:MARTIN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WEST LOOP S
Mailing Address - Street 2:SUITE 1525
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3515
Mailing Address - Country:US
Mailing Address - Phone:713-965-9998
Mailing Address - Fax:866-965-9921
Practice Address - Street 1:2100 WEST LOOP S
Practice Address - Street 2:SUITE 1525
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-3515
Practice Address - Country:US
Practice Address - Phone:713-965-9998
Practice Address - Fax:866-965-9921
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2058760172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker