Provider Demographics
NPI:1669765350
Name:EAGLETON, MARY KATHRYN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:EAGLETON
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0039531208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01912556OtherMEDICARE RAIL ROAD
TX376763401Medicaid
TX75-2616977-118OtherTRICARE
TX8HE842OtherBCBS