Provider Demographics
NPI:1073576203
Name:CAMERON, MARY L (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:CAMERON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:CAMERON-CRONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:100 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6337
Practice Address - Country:US
Practice Address - Phone:507-334-3921
Practice Address - Fax:507-384-4545
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37603207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN910219100Medicaid
MN110014418Medicare PIN
MN910219100Medicaid