Provider Demographics
NPI:1376545616
Name:VAN SICKLE, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:VAN SICKLE
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:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-395-2288
Mailing Address - Fax:505-983-8135
Practice Address - Street 1:7777 SOUTHWEST FWY
Practice Address - Street 2:STE 616
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1802
Practice Address - Country:US
Practice Address - Phone:713-773-3983
Practice Address - Fax:713-271-4076
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5211207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0063PAOtherBLUE CROSS ID
TX8F6437Medicare PIN
TXE14303Medicare UPIN