Provider Demographics
NPI:1881779635
Name:COULTER, MARY ELLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:COULTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:COULTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1940 NW MONTEREY PINES DR
Mailing Address - Street 2:#4
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-5288
Mailing Address - Country:US
Mailing Address - Phone:541-390-8135
Mailing Address - Fax:541-390-8010
Practice Address - Street 1:550 NW HILL ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2951
Practice Address - Country:US
Practice Address - Phone:541-312-4426
Practice Address - Fax:541-312-8010
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine