Provider Demographics
NPI:1578667739
Name:GERARD, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:GERARD
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 1:333 N 18TH AVE
Mailing Address - Street 2:STE B4
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-2233
Mailing Address - Fax:208-232-2299
Practice Address - Street 1:333 N 18TH AVE STE B4
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-2233
Practice Address - Fax:208-232-2299
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM70592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002119100Medicaid
ID70599OtherBLUE CROSS
ID000010008867OtherBLUE SHIELD
ID1134892Medicare PIN
ID000010008867OtherBLUE SHIELD