Provider Demographics
NPI:1518021732
Name:ROPER, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:ROPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60233
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0233
Mailing Address - Country:US
Mailing Address - Phone:361-985-1221
Mailing Address - Fax:361-985-1295
Practice Address - Street 1:4444 CORONA DR
Practice Address - Street 2:SUITE 215
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4324
Practice Address - Country:US
Practice Address - Phone:361-985-1221
Practice Address - Fax:361-985-1295
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6705207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045556004Medicaid
TX045556004Medicaid