Provider Demographics
NPI:1679600647
Name:EWING, MARY L
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:EWING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 W 78TH CIR
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003-2335
Mailing Address - Country:US
Mailing Address - Phone:303-422-0645
Mailing Address - Fax:
Practice Address - Street 1:2500 S HAVANA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1618
Practice Address - Country:US
Practice Address - Phone:303-338-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
008923OtherKAISER-COMMERCIAL NUMBER