Provider Demographics
NPI:1568454106
Name:VADER, MARY LOUISE (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:VADER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:HAMMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:947 SO 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-8897
Practice Address - Street 1:947 SO 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5716
Practice Address - Country:US
Practice Address - Phone:970-249-2421
Practice Address - Fax:970-249-8897
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51283361Medicaid
CO01304310Medicaid
CO01304310Medicaid
COBV2469624Medicare ID - Type Unspecified