Provider Demographics
NPI:1235133265
Name:CHIASSON, MARY J (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:CHIASSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CHICAGO AVE SOUTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1320
Mailing Address - Country:US
Mailing Address - Phone:612-879-1000
Mailing Address - Fax:612-879-9116
Practice Address - Street 1:2828 CHICAGO AVE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1320
Practice Address - Country:US
Practice Address - Phone:612-879-1000
Practice Address - Fax:612-879-9116
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN402472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN446025100Medicaid
MN130000749Medicare ID - Type Unspecified
MN634347Medicare UPIN
MN446025100Medicaid