Provider Demographics
NPI:1760485437
Name:MAILLOUX, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:MAILLOUX
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 1:4074 SW 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2205
Mailing Address - Country:US
Mailing Address - Phone:954-476-5891
Mailing Address - Fax:
Practice Address - Street 1:3333 W COMMERCIAL BLVD
Practice Address - Street 2:STE 210
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-3407
Practice Address - Country:US
Practice Address - Phone:877-751-1157
Practice Address - Fax:919-425-1596
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62993207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23714OtherMEDICARE CORE
FL374172900Medicaid
FL374172900Medicaid
FL23714IMedicare PIN
FL23714HMedicare PIN
FL23714OtherMEDICARE CORE