Provider Demographics
NPI:1861477481
Name:BUSTAMANTE, SARA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:TVRDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 PINCKNEY BLVD
Mailing Address - Street 2:PO BOX 6216A
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6148
Mailing Address - Country:US
Mailing Address - Phone:843-228-5577
Mailing Address - Fax:843-228-5196
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6148
Practice Address - Country:US
Practice Address - Phone:843-228-5577
Practice Address - Fax:843-228-5196
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN