Provider Demographics
NPI:1962680389
Name:MARYRITA KAISER MALLET,MD PA
Entity Type:Organization
Organization Name:MARYRITA KAISER MALLET,MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARYRITA
Authorized Official - Middle Name:KAISER
Authorized Official - Last Name:MALLET
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:817-613-1942
Mailing Address - Street 1:PO BOX 1976
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-7976
Mailing Address - Country:US
Mailing Address - Phone:817-613-1942
Mailing Address - Fax:817-341-3882
Practice Address - Street 1:116 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6548
Practice Address - Country:US
Practice Address - Phone:817-613-1942
Practice Address - Fax:817-341-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ43222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG36229Medicare UPIN
TX00609VMedicare PIN