1336176387 NPI number — DR. MARIA AUDRIE DE JESUS MD

Table of content: (NPI 1851338677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336176387 NPI number — DR. MARIA AUDRIE DE JESUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE JESUS
Provider First Name:
MARIA
Provider Middle Name:
AUDRIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAGRIMAS
Provider Other First Name:
MARIA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336176387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13330 NOEL ROAD
Provider Second Line Business Mailing Address:
APT 338
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-255-0294
Provider Business Mailing Address Fax Number:
434-277-2772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 THROCKMORTON STREET
Provider Second Line Business Practice Location Address:
UNIT 3309
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-908-8124
Provider Business Practice Location Address Fax Number:
817-885-7339
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  P4641 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3099038 . This is a "GHI HEALTH PLANS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 01872586 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53N521 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 30440476 . This is a "MAGNACARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DM6602 . This is a "ATLANTIS BEHAVIORAL HEALT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3241805 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 030440476DE02 . This is a "CARE PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2399196 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 206602 . This is a "HIP HEALTH PLAN OF NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3283244 07 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4C9461 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7745380 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 902408901 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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