Provider Demographics
NPI:1982663001
Name:LOEB, MARY A (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:LOEB
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:RONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:2073 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3413
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:541-682-3551
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD165012207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500666605Medicaid
OR500666605Medicaid