Provider Demographics
NPI:1154427227
Name:POWDERLY, MARY K (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:POWDERLY
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6163
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1263 W ROSEDALE ST STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2837
Practice Address - Country:US
Practice Address - Phone:817-336-4896
Practice Address - Fax:817-332-2805
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3784208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132484100OtherFIRSTCARE PIN
TX10007436OtherAMERIGROUP PIN
TX7742381OtherAETNA PIN
TX1998077OtherFIRSTHEALTH PIN
TX9167363OtherCIGNA PIN
1750369203OtherGRP NPI NUMBER
TX2217850OtherUHC PIN
TX8F9940OtherBCBSTX IND PIN
1750369203OtherGRP NPI NUMBER
TX9167363OtherCIGNA PIN
TX7742381OtherAETNA PIN
TX140442852Medicaid
TX1998077OtherFIRSTHEALTH PIN
TX151839101Medicaid
TX151839101Medicaid
TX8043B7Medicare PIN
TX137345810Medicaid