Provider Demographics
NPI:1942260062
Name:BUENDIA, MARY LOU (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:BUENDIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E SUNBURY ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-4881
Mailing Address - Country:US
Mailing Address - Phone:570-644-0893
Mailing Address - Fax:570-644-0894
Practice Address - Street 1:2 E SUNBURY ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-4881
Practice Address - Country:US
Practice Address - Phone:570-644-0893
Practice Address - Fax:570-644-0894
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030688E2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009395140002Medicaid
PAB30350Medicare UPIN