Provider Demographics
NPI:1255450797
Name:HANNAMAN, MARY R (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:HANNAMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 16533
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0533
Mailing Address - Country:US
Mailing Address - Phone:817-269-6872
Mailing Address - Fax:817-393-1798
Practice Address - Street 1:5012 TRINITY LANDING DR W
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3736
Practice Address - Country:US
Practice Address - Phone:817-269-6872
Practice Address - Fax:817-393-1798
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7318208D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L9076Medicare PIN