Provider Demographics
NPI:1346229978
Name:BUSSO, MARIANO (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:
Last Name:BUSSO
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 AVIATION AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:COCONUT GROVE
Mailing Address - State:FL
Mailing Address - Zip Code:33133-3863
Mailing Address - Country:US
Mailing Address - Phone:305-857-0144
Mailing Address - Fax:
Practice Address - Street 1:3006 AVIATION AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-3863
Practice Address - Country:US
Practice Address - Phone:305-857-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065566207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376308100Medicaid
FL23975Medicare PIN
FLF77212Medicare UPIN