Provider Demographics
NPI:1790741254
Name:PORISCH, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:PORISCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1510 BELCLAIRE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4493
Mailing Address - Country:US
Mailing Address - Phone:210-292-6635
Mailing Address - Fax:210-292-7902
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:SUITE 272
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-614-3264
Practice Address - Fax:210-615-0888
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL09072080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00609XMedicare UPIN
TX8K0631Medicare PIN