Basic Information
| Provider Information | |||||||||
| NPI: | 1902856800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BELVA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760225934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176620008 | ||||||||
| FaxNumber: | 8173910030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G2110 | TX | N | Other Service Providers | Specialist | 208600000X | G2110 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 098287804 | 05 | TX | MEDICAID | 098287805 | 05 | TX | MEDICAID | 8G1590 | 01 | TX | BCBS | OTHER | 098287803 | 05 | TX | MEDICAID |