Provider Demographics
NPI:1437236346
Name:PEASE, MARY IATRIDIS (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:IATRIDIS
Last Name:PEASE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 N ILLINOIS ST
Practice Address - Street 2:SUITE 245
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3100
Practice Address - Country:US
Practice Address - Phone:317-249-2703
Practice Address - Fax:317-249-2708
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059346207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200084970Medicaid
IN200084970Medicaid
IN151560E5Medicare PIN
IN233020BMedicare UPIN