Basic Information
| Provider Information | |||||||||
| NPI: | 1518966647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PASTOR | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PASTOR | ||||||||
| OtherFirstName: | MARY GRACE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485076 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Practice Location | |||||||||
| Address1: | 4450 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098321924 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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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 | 207Q00000X | K6214 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 126826002 | 05 | TX | MEDICAID | 080462703 | 05 | TX | MEDICAID |