Provider Demographics
NPI:1619103058
Name:MBONU, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MBONU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 COLLEGE DR
Mailing Address - Street 2:STE 202
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3536
Mailing Address - Country:US
Mailing Address - Phone:903-614-5330
Mailing Address - Fax:903-735-5320
Practice Address - Street 1:1400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3536
Practice Address - Country:US
Practice Address - Phone:903-614-5330
Practice Address - Fax:903-735-5320
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP4784OtherMEDICAL LICENSE
TX264785YMQ4OtherMEDICARE