MEDICARE: KAPUSTA COSMETIC AND MEDICAL VEIN CENTER, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	F0537	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0087KZ	OTHER	TX	BCBS GROUP

General Provider Information

NPI Number	:	1538343652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAPUSTA COSMETIC AND MEDICAL VEIN CENTER, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 6730
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77265-6730
Country	:	US
Telephone Number	:	713-349-8346
Fax Number	:	713-218-8346

Provider Business Practice Location Address
First Line	:	5585 WESLAYAN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1941
Country	:	US
Telephone Number	:	713-349-8346
Fax Number	:	713-218-8346

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIO OSVALDO KAPUSTA
Credential	:	M.D.
Telephone Number	:	713-349-8346

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	12/26/2007

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