Provider Demographics
NPI:1629008495
Name:COPLEY, MARY SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SANDRA
Last Name:COPLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SANDRA
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1448 10TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3581
Mailing Address - Country:US
Mailing Address - Phone:304-529-0753
Mailing Address - Fax:304-529-0591
Practice Address - Street 1:1448 10TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3581
Practice Address - Country:US
Practice Address - Phone:304-529-0753
Practice Address - Fax:304-529-0591
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16628207Q00000X
KY42930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0942109Medicaid
WV9358681OtherMEDICARE GROUP
KY64699838Medicaid
WV0044781000Medicaid
WV9358681OtherMEDICARE GROUP
WVP01671000Medicare Oscar/Certification
WVWV4591IMedicare PIN
WVC04175651Medicare ID - Type Unspecified
KY64699838Medicaid