Provider Demographics
NPI:1558700161
Name:ALSUP, MARY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:ALSUP
Suffix:
Gender:F
Credentials:OD
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 6362
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-6362
Mailing Address - Country:US
Mailing Address - Phone:361-929-5319
Mailing Address - Fax:844-272-9788
Practice Address - Street 1:6101 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2470
Practice Address - Country:US
Practice Address - Phone:361-929-5319
Practice Address - Fax:844-272-9788
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8201-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4259723Medicaid