Healthcare Provider Details

I. General information

NPI: 1235117680
Provider Name (Legal Business Name): MARY F. ICE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17080 RED OAK DR
HOUSTON TX
77090-2602
US

IV. Provider business mailing address

714 FM 1960 RD W SUITE 206
HOUSTON TX
77090-3405
US

V. Phone/Fax

Practice location:
  • Phone: 281-880-6991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberK7441
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: