Provider Demographics
NPI:1740231430
Name:BUSTILLO, MAYRA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:S
Last Name:BUSTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2335
Practice Address - Street 1:1115 WEBER ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:LA
Practice Address - Zip Code:70538-4124
Practice Address - Country:US
Practice Address - Phone:337-828-2550
Practice Address - Fax:337-355-2335
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL63082080P0214X
LA12129R2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081278601Medicaid
LA1533467Medicaid
TXG26421Medicare UPIN
LA1533467Medicaid