MEDICARE: DR. MALEA PRUSZENSKI MAYNARD 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	207Q00000X	Family Medicine Physician	K7451	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00240298	OTHER	TX	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8147K4	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1740219229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALEA PRUSZENSKI MAYNARD M.D.

Provider Business Mailing Address
First Line	:	8080 N CENTRAL EXPY
Second Line	:	SUITE 1650
City	:	DALLAS
State	:	TX
Zip	:	75206-1838
Country	:	US
Telephone Number	:	972-860-8648
Fax Number	:	972-860-8679

Provider Business Practice Location Address
First Line	:	13350 TI BLVD
Second Line	:	M/S 327
City	:	DALLAS
State	:	TX
Zip	:	75243-1512
Country	:	US
Telephone Number	:	972-671-9504
Fax Number	:	972-671-7096

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/13/2023

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