Provider Demographics
NPI:1104822782
Name:MABRY, DWAN SHIRMELLE (MD)
Entity Type:Individual
Prefix:
First Name:DWAN
Middle Name:SHIRMELLE
Last Name:MABRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:SHIRMELLE
Other - Last Name:MABRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:15748 MEDICAL ARTS DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1446
Mailing Address - Country:US
Mailing Address - Phone:985-542-0663
Mailing Address - Fax:985-542-7010
Practice Address - Street 1:15748 MEDICAL ARTS DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1446
Practice Address - Country:US
Practice Address - Phone:985-542-0663
Practice Address - Fax:985-542-7010
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.022096207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491853Medicaid
LA1491853Medicaid
LA5A557Medicare ID - Type Unspecified