Provider Demographics
NPI:1790380236
Name:BUSTILLO DOCTOR OFFICE INC
Entity Type:Organization
Organization Name:BUSTILLO DOCTOR OFFICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORTENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-879-3071
Mailing Address - Street 1:7295I SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7295I SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1401
Practice Address - Country:US
Practice Address - Phone:786-879-3071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty