Provider Demographics
NPI:1235117680
Name:ICE, MARY F (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:ICE
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 1:714 FM 1960 RD W
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17080 RED OAK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2602
Practice Address - Country:US
Practice Address - Phone:281-880-6991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK74412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1519159-04Medicaid
TXP00303832OtherRAILROAD MEDICARE
TX8G5264Medicare PIN
TX8F5679Medicare PIN
TXP00303832OtherRAILROAD MEDICARE
TXH64936Medicare UPIN