Provider Demographics
NPI:1164790994
Name:EADES, MARY DAN (MD)
Entity Type:Individual
Prefix:
First Name:MARY DAN
Middle Name:
Last Name:EADES
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 1:6525 GUNPARK DR # 150-504
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3346
Mailing Address - Country:US
Mailing Address - Phone:720-340-6306
Mailing Address - Fax:805-565-3142
Practice Address - Street 1:6525 GUNPARK DR # 150-504
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3346
Practice Address - Country:US
Practice Address - Phone:720-340-6306
Practice Address - Fax:805-565-3142
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36065208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice