Provider Demographics
NPI:1336144534
Name:PUSTAVER, MARK R (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:PUSTAVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:4213 MATTHEWS MINT HILL RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-3634
Mailing Address - Country:US
Mailing Address - Phone:704-573-2400
Mailing Address - Fax:704-573-1070
Practice Address - Street 1:4213 MATTHEWS MINT HILL RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-3634
Practice Address - Country:US
Practice Address - Phone:704-573-2400
Practice Address - Fax:704-573-1070
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2011-06-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC1509111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900047Medicaid
NC0872MOtherBLUE CROSS BLUE SHIELD
NC5900047Medicaid