Provider Demographics
NPI:1285788521
Name:O'REILLY, MARTHA LEE (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LEE
Last Name:O'REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:LEE
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-0072
Mailing Address - Country:US
Mailing Address - Phone:254-675-8621
Mailing Address - Fax:254-675-2254
Practice Address - Street 1:201 S AVENUE T
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1855
Practice Address - Country:US
Practice Address - Phone:254-675-8621
Practice Address - Fax:254-675-2254
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA0144262OtherDPS
TX178996802Medicaid
B09587772OtherDEA
319537YVW4Medicare PIN
TXA0144262OtherDPS
P00410457Medicare PIN
319537YVWJMedicare PIN
TX178996802Medicaid