Provider Demographics
NPI:1801889282
Name:BUSTAMANTE, MARTHA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 W 16TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5853
Mailing Address - Country:US
Mailing Address - Phone:305-826-5655
Mailing Address - Fax:305-826-5598
Practice Address - Street 1:4160 W 16TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5853
Practice Address - Country:US
Practice Address - Phone:305-826-5655
Practice Address - Fax:305-826-5598
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME585342084N0008X, 2084N0400X, 2084P0005X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056888100Medicaid
FL1009253OtherWELL CARE
FL1009253OtherCARE PLUS
FL10569OtherSTAYWELL HEALTH PLAN
FL000X0OtherPREFERRED CARE PARTNERS
FL030592OtherNEIGHBORHOOD HEALTH PARTN
FL0480159OtherUNITED HEALTHCARE
FL209062OtherAVMED
FL4549722OtherAETNA US HEALTHCARE
FLP00049OtherDOCTOR CARE
FLE81192OtherVISTA HEALTH PLAN
FL11919OtherBLUE CROSS BLUE SHIELD
FL6130443OtherCIGNA
FL10569OtherSTAYWELL
FL130017008OtherRAILROAD MEDICARE
FL2029711OtherAETNA US HEALTHCARE
FL204828OtherAMERIGROUP
FL130017008OtherRAILROAD MEDICARE
FL056888100Medicaid