MEDICARE: DR. MARY QUICENO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	L6149	TX

General Provider Information

NPI Number	:	1497754162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY QUICENO M.D.

Provider Business Mailing Address
First Line	:	855 MONTGOMERY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2553
Country	:	US
Telephone Number	:	817-735-2200
Fax Number	:	817-735-5441

Provider Business Practice Location Address
First Line	:	855 MONTGOMERY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2553
Country	:	US
Telephone Number	:	817-735-2200
Fax Number	:	817-735-5441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	02/09/2018

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