Provider Demographics
NPI:1972547818
Name:HEBERT, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:HEBERT
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 1:4920 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1254
Mailing Address - Country:US
Mailing Address - Phone:936-558-3715
Mailing Address - Fax:936-558-3701
Practice Address - Street 1:4920 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1254
Practice Address - Country:US
Practice Address - Phone:936-558-3715
Practice Address - Fax:936-558-3701
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130455562085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129804403Medicaid
TX129804405Medicaid
TX129804406Medicaid
TX129804402Medicaid
OK100033980AMedicaid
TX129804404Medicaid
TX129804404Medicaid
TX129804405Medicaid
TX87790KMedicare PIN
TX920001955Medicare PIN
TXF93133Medicare UPIN
TX129804405Medicaid