Provider Demographics
NPI:1124584230
Name:BUSTAMANTE, RENE S (DOM, AP)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:S
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:DOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14972 SW 173RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-6756
Mailing Address - Country:US
Mailing Address - Phone:305-542-4509
Mailing Address - Fax:
Practice Address - Street 1:7480 SW 40TH ST STE 840
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6660
Practice Address - Country:US
Practice Address - Phone:305-814-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4009171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP4009OtherAP4009