1700810173 NPI number — PETER BUSTOS

Table of content: PETER BUSTOS (NPI 1700810173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700810173 NPI number — PETER BUSTOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTOS
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700810173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22796 COLORADO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77365-4689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-743-2386
Provider Business Mailing Address Fax Number:
281-354-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 E PAULINE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77301-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-743-2386
Provider Business Practice Location Address Fax Number:
281-354-1300
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  187002 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 175938301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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