Provider Demographics
NPI:1538293287
Name:BUSTO, EMERIO M (MD)
Entity Type:Individual
Prefix:
First Name:EMERIO
Middle Name:M
Last Name:BUSTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953
Mailing Address - Country:US
Mailing Address - Phone:321-639-5787
Mailing Address - Fax:321-639-5762
Practice Address - Street 1:611 SINGLETON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-269-6389
Practice Address - Fax:321-383-5127
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME21640208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05352ZMedicare ID - Type Unspecified
D21013Medicare UPIN