Basic Information
| Provider Information | |||||||||
| NPI: | 1154427227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWDERLY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 733784 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753733784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828856163 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1263 W ROSEDALE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173364896 | ||||||||
| FaxNumber: | 8173322805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | L3784 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | L3784 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.