Provider Demographics
NPI:1396908505
Name:BUSTOS, SARAH (MD)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:MORALLO
Other - Last Name:OLASO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:950 WOODLAKE RD
Mailing Address - Street 2:
Mailing Address - City:KOHLER
Mailing Address - State:WI
Mailing Address - Zip Code:53044-1348
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:950 WOODLAKE RD
Practice Address - Street 2:
Practice Address - City:KOHLER
Practice Address - State:WI
Practice Address - Zip Code:53044-1348
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.31121207Q00000X
PAMT193190207Q00000X
WI62136-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine