Provider Demographics
NPI:1700335759
Name:BUSTOS, MARIA TERESA AMPUDIA (MD)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:TERESA AMPUDIA
Last Name:BUSTOS
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 1:4275 EXECUTIVE SQUARE, STE 200
Mailing Address - Street 2:P.P.S.
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AV. CALZADA TECNOLOGICO #13999-A 104
Practice Address - Street 2:OTAY, PLAZA ALTABRISA
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22420
Practice Address - Country:MX
Practice Address - Phone:01152664-624-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ834382152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist