Provider Demographics
NPI:1386602563
Name:BAQUERO-BUENO, MARIO RAUL (M D)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:RAUL
Last Name:BAQUERO-BUENO
Suffix:
Gender:M
Credentials:M D
Other - Prefix:DR
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:BAQUERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-0306
Mailing Address - Country:US
Mailing Address - Phone:724-746-5430
Mailing Address - Fax:724-942-8950
Practice Address - Street 1:105 SALISBURY DR
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3617
Practice Address - Country:US
Practice Address - Phone:724-746-5430
Practice Address - Fax:724-942-8950
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-033734-L207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA812275Medicaid
PA812275Medicaid
PABA113114Medicare ID - Type UnspecifiedPROVIDER NUMBER