Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | E4506 | TX |
N | 207NS0135X | Procedural Dermatology | E4506 | TX |
NPI | 1225104672 |
---|---|
Provider Name | Dr. Michael L. Maris |
First Address | Dallas, TX 75234-7852 |
Second Address | Dallas, TX 75234-7852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2006 |
Last Update Date | 28/05/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00D28C | GROUP MEDICARE (01) | TX |
C18785 | (02) | |
D28C | GROUP BCBS (01) | TX |