Provider Demographics
NPI:1801895727
Name:KAWAN, MARY B (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:B
Last Name:KAWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4865 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3508
Mailing Address - Country:US
Mailing Address - Phone:267-425-9800
Mailing Address - Fax:267-425-9999
Practice Address - Street 1:4865 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3508
Practice Address - Country:US
Practice Address - Phone:267-425-9800
Practice Address - Fax:267-425-9999
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23275208000000X
NJ25MA09049500208000000X
PAMD432359208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC122786Medicare UPIN