Healthcare Provider Details

I. General information

NPI: 1780637207
Provider Name (Legal Business Name): MARYAM RAZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N BECKLEY AVE
DALLAS TX
75203-1201
US

IV. Provider business mailing address

559 E OVILLA RD
RED OAK TX
75154-3505
US

V. Phone/Fax

Practice location:
  • Phone: 214-947-5000
  • Fax:
Mailing address:
  • Phone: 214-286-6565
  • Fax: 817-533-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number01680
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM2037
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: