Provider Demographics
NPI:1568689545
Name:BONE, MARY ALICE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:BONE
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 1108
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766
Mailing Address - Country:US
Mailing Address - Phone:903-586-6191
Mailing Address - Fax:903-586-3572
Practice Address - Street 1:510 E. COMMERCE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766
Practice Address - Country:US
Practice Address - Phone:903-586-6191
Practice Address - Fax:903-586-3572
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC49462083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130736505Medicaid
TXPH0717OtherMEDICARE PTAN