Provider Demographics
NPI:1699831586
Name:FRAGILE, MARY LOU (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:FRAGILE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 N NAVARRO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3905
Mailing Address - Country:US
Mailing Address - Phone:361-576-4100
Mailing Address - Fax:361-576-4103
Practice Address - Street 1:2806 N NAVARRO ST
Practice Address - Street 2:SUITE B
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-3905
Practice Address - Country:US
Practice Address - Phone:361-576-4100
Practice Address - Fax:361-576-4103
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV1839207Q00000X
TXN3031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0062XGOtherBLUE CROSS
TX202614801Medicaid
TX8BH061OtherBLUE CROSS
TX202614801Medicaid
TX8L14097Medicare PIN
TXTXB151428Medicare PIN