Basic Information
Provider Information | |||||||||
NPI: | 1003074691 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FELDMAN | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3170 KETTERING BLVD | ||||||||
Address2: | BLDG B 3RD FL | ||||||||
City: | MORAINE | ||||||||
State: | OH | ||||||||
PostalCode: | 454391924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9379913188 | ||||||||
FaxNumber: | 9372239811 | ||||||||
Practice Location | |||||||||
Address1: | 30 E APPLE ST STE 5254A | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 45409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372084200 | ||||||||
FaxNumber: | 9372084205 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2008 | ||||||||
LastUpdateDate: | 10/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A2900X | 16666 | NH | N |   |   |   |   | 2084N0400X | 16666 | NH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | LT4136 | NH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 34.012642 | OH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 102380162 | 05 | PA |   | MEDICAID | 0217667 | 05 | OH |   | MEDICAID |