Provider Demographics
NPI:1003911611
Name:REEVES, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:REEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANDERSON
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:910 RUSH DR
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9665
Mailing Address - Country:US
Mailing Address - Phone:719-539-6637
Mailing Address - Fax:719-539-5275
Practice Address - Street 1:910 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9665
Practice Address - Country:US
Practice Address - Phone:719-539-6637
Practice Address - Fax:719-539-5275
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01310580Medicaid
CO01310580Medicaid
COCC2848Medicare PIN