Healthcare Provider Details

I. General information

NPI: 1801871769
Provider Name (Legal Business Name): MARY T BUSOWSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7893
  • Fax: 407-425-5203
Mailing address:
  • Phone: 321-841-7893
  • Fax: 407-425-5203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME92571
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME92571
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberME92571
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: