Provider Demographics
NPI:1578633194
Name:CHAVEZ, MARY ANN (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1120 N SECTION ST
Mailing Address - Street 2:SULLIVAN MEDICAL CLINIC
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-9200
Mailing Address - Country:US
Mailing Address - Phone:812-268-3901
Mailing Address - Fax:812-268-0674
Practice Address - Street 1:1120 N SECTION ST
Practice Address - Street 2:SULLIVAN MEDICAL CLINIC
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-9200
Practice Address - Country:US
Practice Address - Phone:812-268-3901
Practice Address - Fax:812-268-0674
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02002313A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200343440Medicaid
IN200343440Medicaid
IN179820Medicare PIN