Provider Demographics
NPI:1821317579
Name:BUSTOS MUNOZ, SERGIO (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:BUSTOS MUNOZ
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:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-778-8513
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:368 NE FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3088
Practice Address - Country:US
Practice Address - Phone:386-292-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1284662080P0203X
TXFTL# 436652080P0203X
TXP29642080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80287531Medicaid
TX284782403Medicaid
OK200398620 AMedicaid
TX284782401Medicaid
TX284782404Medicaid
TX284782402Medicaid
TX284782401Medicaid
OK200398620 AMedicaid