Provider Demographics
NPI:1033392717
Name:BAYSDON, MARY L (CFOM CFTS)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:BAYSDON
Suffix:
Gender:F
Credentials:CFOM CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3576
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-3576
Mailing Address - Country:US
Mailing Address - Phone:910-272-9900
Mailing Address - Fax:910-671-1983
Practice Address - Street 1:480 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-4880
Practice Address - Country:US
Practice Address - Phone:910-272-9900
Practice Address - Fax:910-671-1983
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFOM0662335E00000X
NCCFTS0275335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1033392717Medicaid