Provider Demographics
NPI:1114244613
Name:CROW, MARY CHUMBLEY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHUMBLEY
Last Name:CROW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5740
Mailing Address - Country:US
Mailing Address - Phone:318-212-3810
Mailing Address - Fax:318-212-3815
Practice Address - Street 1:1811 EAST BERT KOUNS
Practice Address - Street 2:SUITE 400
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5741
Practice Address - Country:US
Practice Address - Phone:318-212-3810
Practice Address - Fax:318-212-3815
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204709207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2106368Medicaid