Provider Demographics
NPI:1689631459
Name:SOPER, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:SOPER
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 1:4220 KNOLLTON RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-3335
Mailing Address - Country:US
Mailing Address - Phone:317-293-3237
Mailing Address - Fax:
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:STE 212
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6601
Practice Address - Country:US
Practice Address - Phone:317-329-7022
Practice Address - Fax:317-329-7030
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026372207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28340Medicare UPIN
IN088420Medicare ID - Type Unspecified