Provider Demographics
NPI:1376501635
Name:SYRQUIN, MAURICE G (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:G
Last Name:SYRQUIN
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 1:3414 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2375
Mailing Address - Country:US
Mailing Address - Phone:214-521-1153
Mailing Address - Fax:214-219-3651
Practice Address - Street 1:3414 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2375
Practice Address - Country:US
Practice Address - Phone:214-521-1153
Practice Address - Fax:214-219-3651
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9162207W00000X, 207WX0107X
CAG69442207W00000X, 207WX0107X
MA73015207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5365042OtherAETNA
TX128119806Medicaid
TX128119807Medicaid
TX180043891OtherRR MEDICARE GRP CJ5857
OK200052580AMedicaid
TX805833OtherBCBS/GRP 00T587
TX128119804Medicaid
OK200052580AMedicaid
TX128119806Medicaid
TX128119804Medicaid
TX8444M3Medicare PIN