Basic Information
| Provider Information | |||||||||
| NPI: | 1962424226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EARL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N. P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ESSJAY RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301219 | ||||||||
| FaxNumber: | 7168171726 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 ESSJAY RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301219 | ||||||||
| FaxNumber: | 7168171726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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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 | F3306841 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02674115 | 05 | NY | MEDICAID | 9511899 | 01 | NY | IHA | OTHER | 5604161 | 01 | NY | COMM BLUE | OTHER | 0026512801 | 01 | NY | UNIVERA | OTHER |