Healthcare Provider Details

I. General information

NPI: 1508174244
Provider Name (Legal Business Name): MARIAN KATHLEEN QUERRY DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 NORTH ST
NACOGDOCHES TX
75961-4406
US

IV. Provider business mailing address

103 WINIFREDS WAY
HALLSVILLE TX
75650-6223
US

V. Phone/Fax

Practice location:
  • Phone: 936-462-4325
  • Fax: 936-205-4019
Mailing address:
  • Phone: 903-331-0506
  • Fax: 903-331-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberK5671
License Number StateTX

VIII. Authorized Official

Name: DR. MARIAN KATHLEEN QUERRY
Title or Position: PRESIDENT
Credential: DO
Phone: 936-462-4325