Provider Demographics
NPI:1417082488
Name:KASHURBA, MARY TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TERESA
Last Name:KASHURBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-8813
Mailing Address - Country:US
Mailing Address - Phone:814-233-8640
Mailing Address - Fax:
Practice Address - Street 1:727 GOUCHER ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-3025
Practice Address - Country:US
Practice Address - Phone:814-255-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032971E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB70287Medicare UPIN