Provider Demographics
NPI:1780637207
Name:RAZA, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:RAZA
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 1:559 E OVILLA RD
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-3505
Mailing Address - Country:US
Mailing Address - Phone:214-286-6565
Mailing Address - Fax:817-533-6015
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016802083P0011X
TXM2037207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BP100OtherBCBS
TX177888802Medicaid
TX8F8771Medicare PIN