Provider Demographics
NPI:1861440505
Name:BUSTOS, ALICE C (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:C
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7220 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4734
Mailing Address - Country:US
Mailing Address - Phone:414-257-8500
Mailing Address - Fax:414-257-8505
Practice Address - Street 1:7220 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4734
Practice Address - Country:US
Practice Address - Phone:414-257-8500
Practice Address - Fax:414-257-8505
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34039-020207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32058200Medicaid
WI32058200Medicaid
WI0246Medicare PIN