Provider Demographics
NPI:1477758084
Name:ELIBOL, MARY ZELIME (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ZELIME
Last Name:ELIBOL
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1300 W LANCASTER AVE STE 205
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3490
Practice Address - Country:US
Practice Address - Phone:817-336-8611
Practice Address - Fax:817-390-2981
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-232250208000000X
NH159492084N0402X
MA2525482084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics