Provider Demographics
NPI:1720484447
Name:BUSTILLO, ERIK (RD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:BUSTILLO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 ALTON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2891
Mailing Address - Country:US
Mailing Address - Phone:305-672-9989
Mailing Address - Fax:786-245-2006
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-672-9989
Practice Address - Fax:786-245-2006
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6526133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered