Basic Information
| Provider Information | |||||||||
| NPI: | 1588617682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARBONE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | TERESE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 13601 PLANTATION ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393430762 | ||||||||
| FaxNumber: | 2393430958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 25MA05494700 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080S0012X | 25MA05494700 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine | 2080S0012X | ME74786 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2061406 | 05 | NJ | MEDICAID |