Provider Demographics
NPI:1184967879
Name:BUSTOS, MICHAEL G
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 LARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4273
Mailing Address - Country:US
Mailing Address - Phone:210-452-7937
Mailing Address - Fax:
Practice Address - Street 1:360 LARCHMONT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4273
Practice Address - Country:US
Practice Address - Phone:210-452-7937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36051171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator