Provider Demographics
NPI:1437646676
Name:BANGURA, MARY ALPHA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALPHA
Last Name:BANGURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 KNOLLWEST DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77072-1021
Mailing Address - Country:US
Mailing Address - Phone:281-513-0068
Mailing Address - Fax:
Practice Address - Street 1:6119 KNOLLWEST DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-1021
Practice Address - Country:US
Practice Address - Phone:281-513-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801647240002251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX648953782OtherSECRETARY OF STATE