Provider Demographics
NPI:1225104672
Name:MARIS, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:MARIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL PARKWAY
Mailing Address - Street 2:#105
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7852
Mailing Address - Country:US
Mailing Address - Phone:972-243-4530
Mailing Address - Fax:972-406-1950
Practice Address - Street 1:9 MEDICAL PARKWAY
Practice Address - Street 2:#105
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7852
Practice Address - Country:US
Practice Address - Phone:972-243-4530
Practice Address - Fax:972-406-1950
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4506207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD28COtherGROUP BCBS
TX00D28COtherGROUP MEDICARE
88G997Medicare PIN
C18785Medicare UPIN
TXD28COtherGROUP BCBS