MEDICARE: MARIANO BUSSO MD PA

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	207NS0135X	Procedural Dermatology Physician	ME0065566	FL

General Provider Information

NPI Number	:	1497060453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIANO BUSSO MD PA

Provider Business Mailing Address
First Line	:	3006 AVIATION AVE
Second Line	:	SUITE 2C
City	:	COCONUT GROVE
State	:	FL
Zip	:	33133-3863
Country	:	US
Telephone Number	:	305-857-0144
Fax Number	:	305-857-0812

Provider Business Practice Location Address
First Line	:	3006 AVIATION AVE
Second Line	:	SUITE 2C
City	:	COCONUT GROVE
State	:	FL
Zip	:	33133-3863
Country	:	US
Telephone Number	:	305-857-0144
Fax Number	:	305-857-0812

Authorized Official
Title or Position	:	MEDICAL DOCTOR/PRESIDENT
Name	:	MARIANO BUSSO
Credential	:	M.D.
Telephone Number	:	305-857-0144

Provider Enumeration Date	:	08/16/2010
Last Update Date	:	08/16/2010

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