Provider Demographics
NPI:1164686150
Name:BUSTAMANTE, PEDRO MANUEL IV (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:MANUEL
Last Name:BUSTAMANTE
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266
Mailing Address - Country:US
Mailing Address - Phone:832-548-5076
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:1415 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:713-523-4897
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP12792084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080462703Medicaid