Provider Demographics
NPI:1619110988
Name:WERICK, MARYMICHAEL SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYMICHAEL
Middle Name:SMITH
Last Name:WERICK
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 1:4431 BAYBERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2051
Mailing Address - Country:US
Mailing Address - Phone:716-228-1159
Mailing Address - Fax:
Practice Address - Street 1:4000 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504
Practice Address - Country:US
Practice Address - Phone:281-784-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3096207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01091219OtherRAILROAD MEDICARE
TX1619110988OtherTRICARE
TX303109801Medicaid
TX8DH241OtherBLUE CROSS BLUE SHIELD OF TEXAS
TXP01091219OtherRAILROAD MEDICARE