Provider Demographics
NPI:1467543686
Name:BUSTOS, ELWIN G (MD)
Entity type:Individual
Prefix:DR
First Name:ELWIN
Middle Name:G
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1140 VARNUM ST NE PMB 202
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2151
Mailing Address - Country:US
Mailing Address - Phone:202-269-6430
Mailing Address - Fax:202-269-6598
Practice Address - Street 1:1140 VARNUM ST NE PMB 202
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2151
Practice Address - Country:US
Practice Address - Phone:202-269-6430
Practice Address - Fax:202-269-6598
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048655207RN0300X, 302R00000X, 305R00000X
DCMD19909207RN0300X, 261QP2300X, 302R00000X, 305R00000X, 305S00000X, 174400000X
MDD0042936207RN0300X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011630100Medicaid
DC055092400Medicaid
110167563OtherRAILROAD
541897047OtherALL OTHER INSURANCES
96121OtherAMERIGROUP
44320001OtherBCBSHIELD
0401616OtherEVERCARE MARYLAND
1059OtherELDER HEALTH
DC09D0948025OtherCLIA
S10081OtherCHARTERED HEALTH PLAN
MD825900200Medicaid