=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336176387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA AUDRIE DE JESUS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 THROCKMORTON STREET UNIT 3309
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-908-8124
-----------------------------------------------------
Fax | 817-885-7339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13330 NOEL ROAD APT 338
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-255-0294
-----------------------------------------------------
Fax | 434-277-2772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | P4641
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------