Provider Demographics
NPI:1881698645
Name:KANSORA, MARY BETH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:KANSORA
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 1:3880 TAMIAMI TRL N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-3504
Mailing Address - Country:US
Mailing Address - Phone:239-659-3937
Mailing Address - Fax:
Practice Address - Street 1:3880 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3504
Practice Address - Country:US
Practice Address - Phone:239-659-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000480207W00000X
FLME131063207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093AGMedicaid
NC093AGOtherBC/BS PROVIDER NUMBER
NCH19498Medicare UPIN
NC89093AGMedicaid