Provider Demographics
NPI:1912937798
Name:DEEKEN, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:DEEKEN
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 1:3348 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1079
Mailing Address - Country:US
Mailing Address - Phone:573-761-7210
Mailing Address - Fax:573-634-8802
Practice Address - Street 1:3348 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1079
Practice Address - Country:US
Practice Address - Phone:573-761-7210
Practice Address - Fax:573-634-8802
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106715208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203845300Medicaid
MOG96551Medicare UPIN
MO203845300Medicaid