Provider Demographics
NPI:1366492621
Name:CHERRY, MARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:CHERRY
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 1:204 HIGHLAND PARK PLAZA
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7233
Mailing Address - Country:US
Mailing Address - Phone:985-809-3883
Mailing Address - Fax:985-809-3886
Practice Address - Street 1:204 HIGHLAND PARK PLZ
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7129
Practice Address - Country:US
Practice Address - Phone:985-809-3883
Practice Address - Fax:985-809-3886
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020710207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1967874Medicaid
LA020710OtherSTATE MEDICAL LICENSE
LAF58566Medicare UPIN
LA1967874Medicaid