1477757334 NPI number — MARIO BUSTAMANTE MD PA

Table of content: MISS NATNICHA LEELAVIWAT MD (NPI 1114691607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477757334 NPI number — MARIO BUSTAMANTE MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIO BUSTAMANTE MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1477757334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12770 CIMARRON PATH
Provider Second Line Business Mailing Address:
SUITE 132
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78249-3416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-733-1802
Provider Business Mailing Address Fax Number:
210-733-1808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12770 CIMARRON PATH
Provider Second Line Business Practice Location Address:
SUITE 132
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78249-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-733-1802
Provider Business Practice Location Address Fax Number:
210-733-1808
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANTU
Authorized Official First Name:
LETICIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
210-733-1802

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  C14004 , 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: 168353401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0076MN . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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