Provider Demographics
NPI:1730359514
Name:LUIS E BUSTOS M.D.,P.C.
Entity type:Organization
Organization Name:LUIS E BUSTOS M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BUSTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-558-5666
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032972261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0205006091OtherBLUE CROSS BLUE SHIELD MI
MI101390582Medicaid
MI0820145Medicare PIN
MI0205006091OtherBLUE CROSS BLUE SHIELD MI