Provider Demographics
NPI:1275760738
Name:HENSON, MARY KATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:HENSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4015 I 45 N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-5074
Mailing Address - Country:US
Mailing Address - Phone:936-270-4600
Mailing Address - Fax:936-856-8429
Practice Address - Street 1:4015 I 45 N
Practice Address - Street 2:SUITE 100
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-5074
Practice Address - Country:US
Practice Address - Phone:936-270-4600
Practice Address - Fax:936-856-8429
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP4763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX319276702Medicaid
TX8FX814OtherBCBS
TX8FX814OtherBCBS