Provider Demographics
NPI:1932108545
Name:DE BUSTROS, ANDREE C (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREE
Middle Name:C
Last Name:DE BUSTROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREE
Other - Middle Name:C
Other - Last Name:CHINIARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5525 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4400
Mailing Address - Country:US
Mailing Address - Phone:312-567-7500
Mailing Address - Fax:
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:312-567-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081805207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3323019OtherMEDICARE PTAN
IL036081805Medicaid
IL326170152OtherTAX ID
IL01621253OtherBLUE SHIELD NUMBER
IL231199Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ILP00222927Medicare ID - Type UnspecifiedILL RR MEDICARE