Provider Demographics
NPI:1518355494
Name:BUSTOS, DEREK (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1978
Mailing Address - Country:US
Mailing Address - Phone:906-487-1710
Mailing Address - Fax:906-487-9421
Practice Address - Street 1:1000 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1978
Practice Address - Country:US
Practice Address - Phone:906-487-1710
Practice Address - Fax:906-487-9421
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist