Basic Information
| Provider Information | |||||||||
| NPI: | 1558328450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CABRERA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1418 6TH STREET | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239740000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346965555 | ||||||||
| FaxNumber: | 4346961625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME69908 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2202780 | 01 | VA | UHC/MAMSI | OTHER | 1695358 | 01 | VA | CIGNA | OTHER | 4555951 | 01 | VA | AETNA | OTHER | 8202780 | 01 | VA | UHC-PCP | OTHER | 61459604 | 01 | VA | BLACK LUNG/FECA | OTHER |