Provider Demographics
NPI:1821020991
Name:SHEEHAN, MARITA (MD)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:SHEEHAN
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-354-5630
Practice Address - Fax:806-354-5689
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9740208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138314313Medicaid
OK100218140 AMedicaid
NME1575Medicaid
TX138314309Medicaid
TX8L25106Medicare PIN
OK100218140 AMedicaid
NME1575Medicaid