Healthcare Provider Details

I. General information

NPI: 1760779722
Provider Name (Legal Business Name): MARY T CHAMPION MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 STATE LINE RD STE 100
PRAIRIE VILLAGE KS
66208-3447
US

IV. Provider business mailing address

7400 STATE LINE RD STE 100
PRAIRIE VILLAGE KS
66208-3447
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6600
  • Fax: 913-588-6655
Mailing address:
  • Phone: 913-588-6600
  • Fax: 913-588-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number50228
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number50228
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number2020013466
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number0439896
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number1
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: