Provider Demographics
NPI:1629034285
Name:OBEAR, MARY EDITH (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:EDITH
Last Name:OBEAR
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-9753
Mailing Address - Country:US
Mailing Address - Phone:585-599-6446
Mailing Address - Fax:585-599-3166
Practice Address - Street 1:860 MAIN RD
Practice Address - Street 2:
Practice Address - City:CORFU
Practice Address - State:NY
Practice Address - Zip Code:14036-9753
Practice Address - Country:US
Practice Address - Phone:585-599-6446
Practice Address - Fax:585-599-3166
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205518207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01909273Medicaid
NY01909273Medicaid
NYDD2268Medicare ID - Type Unspecified