Provider Demographics
NPI:1437118528
Name:COLE, MARY O (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:O
Last Name:COLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:123 WESTERN HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3446
Mailing Address - Country:US
Mailing Address - Phone:307-635-0226
Mailing Address - Fax:307-635-1924
Practice Address - Street 1:123 WESTERN HILLS BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3446
Practice Address - Country:US
Practice Address - Phone:307-635-0226
Practice Address - Fax:307-635-1924
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY6283A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE83025288813Medicaid
WY310893Medicare ID - Type Unspecified
NE83025288813Medicaid