Provider Demographics
NPI:1730384421
Name:SOON, MARY GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:GRACE
Last Name:SOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SOON
Other - Last Name:STUART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6005 N POINTE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3890
Mailing Address - Country:US
Mailing Address - Phone:706-888-3485
Mailing Address - Fax:
Practice Address - Street 1:4370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1056
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060322208M00000X
HIMD-14409208M00000X
ALMD.33053208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA912934550EMedicaid
HIMD-14409OtherLIC
HIMD-14409OtherLIC
GA912934550EMedicaid