Provider Demographics
NPI:1518054527
Name:TOMASELLI, MARY BETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:TOMASELLI
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1283 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-8314
Practice Address - Country:US
Practice Address - Phone:954-345-2718
Practice Address - Fax:954-753-2683
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49877208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP0004906OtherFLORIDA HEALTHCARE PLUS
FL045418400Medicaid
FL13704OtherWELLCARE
FLP00413913OtherRAILROAD MEDICARE
FL110027564OtherRAILROAD MEDICARE
FLP0004906OtherFLORIDA HEALTHCARE PLUS
FLP00413913OtherRAILROAD MEDICARE