Provider Demographics
NPI:1386881142
Name:UPDYKE, MARY E (RD, LD, CDE)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:UPDYKE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26568 SPRING LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-7613
Mailing Address - Country:US
Mailing Address - Phone:660-665-1436
Mailing Address - Fax:660-665-8949
Practice Address - Street 1:26568 SPRING LAKE TRL
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-7613
Practice Address - Country:US
Practice Address - Phone:660-665-1436
Practice Address - Fax:660-665-8949
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001024034133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ47052Medicare UPIN