Provider Demographics
NPI:1750382099
Name:BUSTOS, LUIS E (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:E
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:29135 RYAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4276
Mailing Address - Country:US
Mailing Address - Phone:586-558-5666
Mailing Address - Fax:586-558-9333
Practice Address - Street 1:29135 RYAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4276
Practice Address - Country:US
Practice Address - Phone:586-558-5666
Practice Address - Fax:586-558-9333
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2009-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301032972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1390582Medicaid
MI0500609OtherBLUE CROSS BLUE SHIELD
MIB44217Medicare UPIN
MI1390582Medicaid