Provider Demographics
NPI:1801886924
Name:TISSERAND, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TISSERAND
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 1:3700 BELLEMEADE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0102
Mailing Address - Country:US
Mailing Address - Phone:812-476-1379
Mailing Address - Fax:
Practice Address - Street 1:3700 BELLEMEADE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0102
Practice Address - Country:US
Practice Address - Phone:812-476-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037184207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INEO3773Medicare UPIN
IN530280Medicare PIN