Provider Demographics
NPI:1275635559
Name:PABLO-BUSTOS, DORIS V (MD)
Entity Type:Individual
Prefix:DR
First Name:DORIS
Middle Name:V
Last Name:PABLO-BUSTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 VARNUM ST NE
Mailing Address - Street 2:#105
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2151
Mailing Address - Country:US
Mailing Address - Phone:202-269-6430
Mailing Address - Fax:202-269-6598
Practice Address - Street 1:1140 VARNUM ST NE
Practice Address - Street 2:#105
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2151
Practice Address - Country:US
Practice Address - Phone:202-269-6430
Practice Address - Fax:202-269-6598
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058776302F00000X, 302R00000X, 305R00000X, 305S00000X
DCMD30307302F00000X, 302R00000X, 305R00000X, 305S00000X, 207R00000X
VA0101056019302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005868734Medicaid
DC030402916OtherBRAVO
VA030402916OtherUNITED HEALTHCARE
VA030402916OtherGREAT WEST
DC033872900Medicaid
DC030402916OtherCIGNA
VA030402916OtherCIGNA
DC030402916OtherUNITED HEALTH CARE
DC030402916OtherGREAT WEST
DC030402916OtherANTHEM BCBS
DCF811-0001OtherCAREFIRST BCBS
DC030402916OtherAETNA
VA030402916OtherTRICARE
VAF811-0001OtherCAREFIRST BCBS
DC00B155D61OtherMEDICARE
VA030402916OtherAETNA
DC030402916OtherGEHA
VA030402916OtherANTHEM BCBS
DC030402916OtherTRICARE
MD510223500Medicaid
DC030402816OtherMAILHANDLERS
DC030402916OtherGEHA