Provider Demographics
NPI:1861576803
Name:BUSTAMANTE, PATRICIA CESAR
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:CESAR
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:561-478-8770
Mailing Address - Fax:561-688-8877
Practice Address - Street 1:10701 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3618
Practice Address - Country:US
Practice Address - Phone:305-225-5471
Practice Address - Fax:305-225-5481
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS3784237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL610250600Medicaid