Provider Demographics
NPI:1952385619
Name:STAUBLE, MARY ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELAINE
Last Name:STAUBLE
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:PO BOX 909
Mailing Address - Street 2:DEPT OB/GYN ATT VICKI MASTERSON
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0329
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 410
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-271-5999
Practice Address - Fax:502-271-5994
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY21058207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200835760Medicaid
KY64210586Medicaid
KY50015262OtherPASSPORT SPECIALTY
000000368677OtherANTHEM
KY50017317OtherPASSPORT PCP
000000507070OtherANTHEM
KY50006479OtherPASSPORT SPECIALTY
KY0722538Medicare PIN
000000507070OtherANTHEM
KY0979710Medicare PIN