Provider Demographics
NPI:1821121120
Name:RELLAHAN, MARY C (DPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:RELLAHAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 GREENSIDE CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3700
Mailing Address - Country:US
Mailing Address - Phone:904-373-0981
Mailing Address - Fax:904-373-0981
Practice Address - Street 1:2308 GREESIDE COURT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3700
Practice Address - Country:US
Practice Address - Phone:904-373-0981
Practice Address - Fax:904-373-0981
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2236213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059783000Medicaid
FL65224OtherBCBS
FL65224ZMedicare PIN
FL059783000Medicaid
U28372Medicare UPIN
FL65224AMedicare PIN