Provider Demographics
NPI:1376546796
Name:MORALES, MARY MONTEMAYOR (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MONTEMAYOR
Last Name:MORALES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 GRAMERCY ST # 400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1756
Mailing Address - Country:US
Mailing Address - Phone:713-668-6828
Mailing Address - Fax:
Practice Address - Street 1:2855 GRAMERCY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1756
Practice Address - Country:US
Practice Address - Phone:713-668-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5357TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041849304Medicaid
TX0149PUOtherBLUE CROSS BLUE SHIELD
TX0418493-02Medicaid