Provider Demographics
NPI:1659440253
Name:REX, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:REX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:REX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:402 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43724-1234
Mailing Address - Country:US
Mailing Address - Phone:740-732-4620
Mailing Address - Fax:740-732-7179
Practice Address - Street 1:402 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:OH
Practice Address - Zip Code:43724
Practice Address - Country:US
Practice Address - Phone:740-732-4620
Practice Address - Fax:740-732-7179
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3891SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0735404Medicaid