Provider Demographics
NPI:1689789513
Name:UPSHAW, MARY (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083-1968
Mailing Address - Country:US
Mailing Address - Phone:334-727-4760
Mailing Address - Fax:334-724-6888
Practice Address - Street 1:2400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-5001
Practice Address - Country:US
Practice Address - Phone:334-727-0550
Practice Address - Fax:334-724-6888
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL498133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered