=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376585547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA NELLA MUSSO D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 09/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94 07 156 AVENUE
-----------------------------------------------------
City | HOWARD BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-641-7180
-----------------------------------------------------
Fax | 718-641-7326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94 07 156 AVE
-----------------------------------------------------
City | HOWARD BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-641-7180
-----------------------------------------------------
Fax | 718-641-7326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 196338
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------