Provider Demographics
NPI:1710421227
Name:BUFORD, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BUFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 NE 78TH CT STE A3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2823
Mailing Address - Country:US
Mailing Address - Phone:503-252-3949
Mailing Address - Fax:
Practice Address - Street 1:6185 PASEO DEL NORTE STE 150
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1155
Practice Address - Country:US
Practice Address - Phone:855-259-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200743610RN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028382Medicaid