Provider Demographics
NPI:1285032219
Name:BUSTOS, LEONARD (DPT)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FRANKLIN TOWN BLVD APT 1203
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1246
Mailing Address - Country:US
Mailing Address - Phone:908-642-4900
Mailing Address - Fax:
Practice Address - Street 1:841 E HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4800
Practice Address - Country:US
Practice Address - Phone:215-437-7210
Practice Address - Fax:215-437-7207
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist