Provider Demographics
NPI:1437268943
Name:KAPUSTA, MARIO OSVALDO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:OSVALDO
Last Name:KAPUSTA
Suffix:
Gender:M
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:PO BOX 6730
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77265-6730
Mailing Address - Country:US
Mailing Address - Phone:713-349-8346
Mailing Address - Fax:713-218-8346
Practice Address - Street 1:5585 WESLAYAN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1941
Practice Address - Country:US
Practice Address - Phone:713-349-8346
Practice Address - Fax:713-218-8346
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11435174400000X
TXF0537174400000X, 2086S0129X
CAC42419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060049733OtherRAILROAD MEDICARE
TX4076907OtherAETNA
TXP082460J2Medicaid
TX134953204Medicaid
TX8M0430OtherBLUE CROSS BLUE SHEILD
TX060049733OtherRAILROAD MEDICARE
TX4076907OtherAETNA
TX760565394OtherEIN
TXP082460J2Medicaid
TXB23840Medicare UPIN