Provider Demographics
NPI:1730175142
Name:GUSTILO, MARY CATHERINE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:GUSTILO
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1868
Mailing Address - Country:US
Mailing Address - Phone:781-952-1480
Mailing Address - Fax:781-952-1481
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-952-1480
Practice Address - Fax:781-952-1481
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA160433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ21691OtherBLUE CROSS
MA710668OtherHARVARD PILGRIM
MA0107051Medicaid
MA0107051Medicaid