Provider Demographics
NPI:1841238771
Name:LOB, MARY A (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:LOB
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 1:21411 BROOKES RUN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-6728
Mailing Address - Country:US
Mailing Address - Phone:402-740-9044
Mailing Address - Fax:
Practice Address - Street 1:5352 N HABANA AVE STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6838
Practice Address - Country:US
Practice Address - Phone:813-756-1956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124755207Q00000X
IA34122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI8519Medicare PIN
IAH71320Medicare UPIN