Provider Demographics
NPI:1356334783
Name:QUERRY, MARIAN KATHLEEN (DO)
Entity type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:KATHLEEN
Last Name:QUERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4406
Mailing Address - Country:US
Mailing Address - Phone:936-462-4325
Mailing Address - Fax:
Practice Address - Street 1:1020 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4406
Practice Address - Country:US
Practice Address - Phone:936-462-4325
Practice Address - Fax:936-205-4019
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5671208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152647702Medicaid
TXG81606Medicare UPIN
TX152647702Medicaid