Provider Demographics
NPI:1700810173
Name:BUSTOS, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:22796 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-4689
Mailing Address - Country:US
Mailing Address - Phone:281-743-2386
Mailing Address - Fax:281-354-1300
Practice Address - Street 1:804 E PAULINE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2465
Practice Address - Country:US
Practice Address - Phone:281-743-2386
Practice Address - Fax:281-354-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1870023416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175938301Medicaid
TX175938301Medicaid