Provider Demographics
NPI:1558190355
Name:MOCTEZUMA DAVILA, MARIANA (MD)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:MOCTEZUMA DAVILA
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 1:6550 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:713-793-1178
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-790-3311
Practice Address - Fax:713-793-1178
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10089072390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program