Provider Demographics
NPI:1669411849
Name:DENE, MARY LOU (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:DENE
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 1:1402 RICE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3230
Mailing Address - Country:US
Mailing Address - Phone:903-630-7691
Mailing Address - Fax:
Practice Address - Street 1:1402 RICE RD STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3230
Practice Address - Country:US
Practice Address - Phone:903-630-7691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37811207R00000X
MO2005024069207R00000X
TXS4123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK207490905Medicaid
KY64062094Medicaid
MO934724475Medicare ID - Type UnspecifiedOKLAHOMA MEDICARE
OK207490905Medicaid
KY64062094Medicaid