Provider Demographics
NPI:1518966647
Name:PASTOR, MARY GRACE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:PASTOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY GRACE
Other - Middle Name:
Other - Last Name:PASTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266
Mailing Address - Country:US
Mailing Address - Phone:832-548-5076
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:4450 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705
Practice Address - Country:US
Practice Address - Phone:409-832-1924
Practice Address - Fax:713-523-4897
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126826002Medicaid
TX080462703Medicaid
TX080462703Medicaid
TX126826002Medicaid