Healthcare Provider Details

I. General information

NPI: 1669765350
Provider Name (Legal Business Name): MARY KATHRYN EAGLETON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8288 S BROADWAY AVE
TYLER TX
75703-5262
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-606-7060
  • Fax:
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP1-0039531
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: