Provider Demographics
NPI:1336176387
Name:DE JESUS, MARIA AUDRIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:AUDRIE
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:A
Other - Last Name:LAGRIMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13330 NOEL ROAD
Mailing Address - Street 2:APT 338
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:914-255-0294
Mailing Address - Fax:434-277-2772
Practice Address - Street 1:500 THROCKMORTON STREET
Practice Address - Street 2:UNIT 3309
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-908-8124
Practice Address - Fax:817-885-7339
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4641204D00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030440476DE02OtherCARE PLUS
NYP3241805OtherOXFORD
NC3099038OtherGHI HEALTH PLANS
NY4C9461OtherHEALTH NET
NY206602OtherHIP HEALTH PLAN OF NY
NY7745380OtherCIGNA HEALTHCARE
NY01872586Medicaid
NY2399196OtherUNITED HEALTHCARE
NY30440476OtherMAGNACARE
NY53N521OtherEMPIRE BCBS
NY902408901OtherAMERICHOICE
TX3283244 07Medicaid
NYDM6602OtherATLANTIS BEHAVIORAL HEALT
TX267456YSFZMedicare PIN
NY902408901OtherAMERICHOICE
NYP3241805OtherOXFORD