Basic Information
| Provider Information | |||||||||
| NPI: | 1114915451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692820996 | ||||||||
| Practice Location | |||||||||
| Address1: | 5802 SARATOGA BLVD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784144252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619864600 | ||||||||
| FaxNumber: | 3619850305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L2933 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | L2933 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 157055804 | 05 | TX | MEDICAID | 1L5763 | 01 | TX | MEDICARE | OTHER | 157055808 | 05 | TX | MEDICAID | P02601766 | 01 | TX | MCRR | OTHER | 00K51Q | 01 | TX | BCBS GROUP/COAST. BND FAM | OTHER | 157055807 | 05 | TX | MEDICAID | 8G1442 | 01 | TX | BCBS | OTHER |