Provider Demographics
NPI:1922189463
Name:SCHIPPER, MARY STARR (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:STARR
Last Name:SCHIPPER
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 1:2910 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3993
Mailing Address - Country:US
Mailing Address - Phone:505-425-2985
Mailing Address - Fax:
Practice Address - Street 1:LAS VEGAS CLINIC FOR CHILDREN & YOUTH
Practice Address - Street 2:501 7TH STREET
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3993
Practice Address - Country:US
Practice Address - Phone:505-425-3566
Practice Address - Fax:505-425-3568
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20030522208000000X
MDD0027946208000000X
PAMD021090E208000000X
WV12493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49395Medicaid
C28639Medicare UPIN
C28639Medicare ID - Type Unspecified