Provider Demographics
NPI:1427077759
Name:ALLEN, MARY JUDITH (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JUDITH
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13592 WAYNESFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-8621
Mailing Address - Country:US
Mailing Address - Phone:419-305-5728
Mailing Address - Fax:
Practice Address - Street 1:303 FRASER DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3712
Practice Address - Country:US
Practice Address - Phone:912-877-2227
Practice Address - Fax:912-877-2332
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA516152080N0001X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3046411Medicaid
OH3046411Medicaid