Provider Demographics
NPI:1073710695
Name:BUSTOS, MARY E (CPOA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:CPOA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 E 185TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-7704
Mailing Address - Country:US
Mailing Address - Phone:917-232-1210
Mailing Address - Fax:
Practice Address - Street 1:3416 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1002
Practice Address - Country:US
Practice Address - Phone:718-325-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156FX1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric Assistant