Provider Demographics
NPI:1598962581
Name:BUSTLE, JOHN PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:BUSTLE
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 1:615 W NURSERY ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-1840
Mailing Address - Country:US
Mailing Address - Phone:660-200-7000
Mailing Address - Fax:660-200-7004
Practice Address - Street 1:615 W NURSERY
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730
Practice Address - Country:US
Practice Address - Phone:660-200-7000
Practice Address - Fax:660-200-7015
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO603000015Medicare PIN