Provider Demographics
NPI:1609033513
Name:MAYO-WALLEY, DENISE CHANELLE (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:CHANELLE
Last Name:MAYO-WALLEY
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 1:5120 WOODWAY DR
Mailing Address - Street 2:SUITE 7012
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-1723
Mailing Address - Country:US
Mailing Address - Phone:713-783-1536
Mailing Address - Fax:
Practice Address - Street 1:4200 TWELVE OAKS DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-6812
Practice Address - Country:US
Practice Address - Phone:713-621-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP3389207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01163091OtherRAILROAD MEDICARE
TX304886001Medicaid
TX304886002Medicaid
TX8DL522OtherBLUE CROSS BLUE SHIELD
TX304886002Medicaid