Provider Demographics
NPI:1588617682
Name:CARBONE, MARY TERESE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TERESE
Last Name:CARBONE
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:13601 PLANTATION ROAD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-343-0762
Practice Address - Fax:239-343-0958
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA054947002080N0001X, 2080S0012X
FLME747862080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2061406Medicaid
E79872Medicare UPIN