Provider Demographics
NPI:1205925716
Name:WHITWORTH, MARY S (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:WHITWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-1485
Practice Address - Fax:817-338-1841
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ91982080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10033718OtherAMERIGROUP PIN
TX1392938OtherUHC PIN
TX2272139OtherCIGNA PIN
TX5775104OtherAETNA PIN
TX1727221OtherFIRSTHEALTH PIN
TX88V632OtherBCBSTX IND PIN
TX00U87ZOtherBCBSTX GRP PIN
TX124069OtherSUPERIOR PIN
TX047103904Medicaid
TX126819100OtherFIRSTCARE PIN
TX126819100OtherFIRSTCARE PIN
G16098Medicare UPIN