Provider Demographics
NPI:1053301424
Name:MCINTYRE, MARY JOANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JOANNA
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:JOANNA
Other - Last Name:GOCALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6505 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3457
Mailing Address - Country:US
Mailing Address - Phone:330-746-9200
Mailing Address - Fax:330-746-9211
Practice Address - Street 1:6505 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-3457
Practice Address - Country:US
Practice Address - Phone:330-746-9200
Practice Address - Fax:330-746-9211
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH82783208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2500350Medicaid
OH2500350Medicaid