Provider Demographics
NPI:1578890216
Name:POCKRUS, MANDY JO (MD)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:JO
Last Name:POCKRUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:J
Other - Last Name:POCKRUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:4035 STATE HIGHWAY 6 S
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8963
Practice Address - Country:US
Practice Address - Phone:979-207-6400
Practice Address - Fax:979-207-6401
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7132207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22020201Medicaid