Provider Demographics
NPI:1396185575
Name:BUSTOS, EMMANUEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 ELBERTSON ST APT 651
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2136
Mailing Address - Country:US
Mailing Address - Phone:718-916-0043
Mailing Address - Fax:
Practice Address - Street 1:2599 BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5686
Practice Address - Country:US
Practice Address - Phone:212-663-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006572213E00000X
NY006572213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist