Healthcare Provider Details

I. General information

NPI: 1639245186
Provider Name (Legal Business Name): MARYANN BUETTI-SGOUROS M.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 S LAKE BLVD
MAHOPAC NY
10541-4771
US

IV. Provider business mailing address

92 W LAKE BLVD
MAHOPAC NY
10541-3133
US

V. Phone/Fax

Practice location:
  • Phone: 845-628-8277
  • Fax:
Mailing address:
  • Phone: 845-628-8277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number202057
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: