Provider Demographics
NPI:1003591132
Name:KOLOKOURIS, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:KOLOKOURIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 WADSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:NY
Mailing Address - Zip Code:14414-1157
Mailing Address - Country:US
Mailing Address - Phone:585-736-8973
Mailing Address - Fax:
Practice Address - Street 1:2099 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14626-2728
Practice Address - Country:US
Practice Address - Phone:607-235-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist