Provider Demographics
NPI:1497060453
Name:MARIANO BUSSO MD PA
Entity Type:Organization
Organization Name:MARIANO BUSSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-857-0144
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:305-857-0812
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:305-857-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065566207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty