Provider Demographics
NPI:1528188133
Name:MARETH, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MARETH
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 1:4730 COLLEGE DR
Mailing Address - Street 2:6515 KEMP BLVD
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-4009
Mailing Address - Country:US
Mailing Address - Phone:940-552-4055
Mailing Address - Fax:
Practice Address - Street 1:4730 COLLEGE DR
Practice Address - Street 2:6515 KEMP BLVD
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-4009
Practice Address - Country:US
Practice Address - Phone:940-552-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2702283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC18779Medicare UPIN
TX8609N4Medicare ID - Type UnspecifiedVERNON PART B
TX8831B8Medicare ID - Type Unspecified