Provider Demographics
NPI:1659553253
Name:DORIS PABLO-BUSTOS, MD PC
Entity Type:Organization
Organization Name:DORIS PABLO-BUSTOS, MD PC
Other - Org Name:DORIS PABLO-BUSTOS, MD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:V
Authorized Official - Last Name:PABLO-BUSTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-269-6430
Mailing Address - Street 1:1140 VARNUM ST NE
Mailing Address - Street 2:PROVIDENCE MEDICAL BLDG STE 202
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2151
Mailing Address - Country:US
Mailing Address - Phone:202-269-6430
Mailing Address - Fax:202-269-6598
Practice Address - Street 1:1140 VARNUM ST NE
Practice Address - Street 2:PROVIDENCE MEDICAL BLDG STE 202
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2151
Practice Address - Country:US
Practice Address - Phone:202-269-6430
Practice Address - Fax:202-269-6598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG00861OtherMEDICARE
DC050883700Medicaid
DCDA9514OtherMEDICARE RAILROAD
VA1659553253Medicaid
MD553223000Medicaid