Provider Demographics
NPI:1962424226
Name:EARL, MARY BETH (N P)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:EARL
Suffix:
Gender:F
Credentials:N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:325 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8243
Practice Address - Country:US
Practice Address - Phone:716-630-1219
Practice Address - Fax:716-817-1726
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3306841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02674115Medicaid
NY9511899OtherIHA
NY5604161OtherCOMM BLUE
NY0026512801OtherUNIVERA
NY0026512801OtherUNIVERA
NYBB5091Medicare ID - Type Unspecified