Healthcare Provider Details

I. General information

NPI: 1619472396
Provider Name (Legal Business Name): LILIANA JULISSA DIAZ BUSTAMANTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14850 ROSCOE BLVD
PANORAMA CITY CA
91402-4618
US

IV. Provider business mailing address

14850 ROSCOE BLVD
PANORAMA CITY CA
91402-4618
US

V. Phone/Fax

Practice location:
  • Phone: 818-787-2222
  • Fax:
Mailing address:
  • Phone: 818-787-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberA198695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: