Basic Information
Provider Information | |||||||||
NPI: | 1972999449 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUARTE THIBAULT | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DUARTE | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6651 MAIN ST STE 1020 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8328267735 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1504 TAUB LOOP | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770301608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8328267313 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2015 | ||||||||
LastUpdateDate: | 10/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | PHYTEMP | TX | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207V00000X | T9386 | TX | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | PHYTEMP | TX | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.