Provider Demographics
NPI:1467543686
Name:BUSTOS, ELWIN G (MD)
Entity Type:Individual
Prefix:MR
First Name:ELWIN
Middle Name:G
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:ELWIN
Other - Middle Name:G
Other - Last Name:BUSTOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:918 HELGA PLACE
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102
Mailing Address - Country:US
Mailing Address - Phone:703-448-8819
Mailing Address - Fax:
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 213
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-269-6430
Practice Address - Fax:202-269-6598
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD19909207RN0300X
MDD0042936207RN0300X
VA0101048655207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0401616OtherEVERCARE MARYLAND
S10081OtherCHARTERED HEALTH PLAN
44320001OtherBCBSHIELD
96121OtherAMERIGROUP
1059OtherELDER HEALTH
0401616OtherEVERCARE MARYLAND
407965Medicare ID - Type Unspecified