Provider Demographics
NPI:1598758187
Name:BUSTILLO, KAREN L (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:L
Last Name:BUSTILLO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W GUADALUPE RD
Mailing Address - Street 2:#313
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3332
Mailing Address - Country:US
Mailing Address - Phone:480-892-0808
Mailing Address - Fax:480-892-6045
Practice Address - Street 1:201 W GUADALUPE RD
Practice Address - Street 2:#313
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3332
Practice Address - Country:US
Practice Address - Phone:480-892-0808
Practice Address - Fax:480-892-6045
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85270Medicare PIN
AZ85272Medicare PIN