Provider Demographics
NPI:1578605010
Name:BUSTILLOS, MATTHEW BENJAMIN (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:BUSTILLOS
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 1:27222 NOGAL
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3422
Mailing Address - Country:US
Mailing Address - Phone:949-367-1598
Mailing Address - Fax:
Practice Address - Street 1:24731 ALICIA PKWY
Practice Address - Street 2:UNIT B
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4653
Practice Address - Country:US
Practice Address - Phone:949-588-7278
Practice Address - Fax:949-588-7331
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT151532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB211808Medicare PIN
CAW17215BMedicare PIN