Provider Demographics
NPI:1669469235
Name:MAXWELL, MARY S (MD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4107 MEDICAL PKWY
Mailing Address - Street 2:#210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3735
Mailing Address - Country:US
Mailing Address - Phone:512-451-4488
Mailing Address - Fax:512-453-2707
Practice Address - Street 1:4107 MEDICAL PKWY STE 210
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3738
Practice Address - Country:US
Practice Address - Phone:512-451-4488
Practice Address - Fax:512-453-2707
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2016-01-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXH0613207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131432004Medicaid
TXC18974Medicare UPIN
TX00B65BMedicare PIN