Healthcare Provider Details

I. General information

NPI: 1275144313
Provider Name (Legal Business Name): SOFIA CARMEN BUSTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 CORAL PL
SEAL BEACH CA
90740-5712
US

IV. Provider business mailing address

1709 CORAL PL
SEAL BEACH CA
90740-5712
US

V. Phone/Fax

Practice location:
  • Phone: 562-588-5143
  • Fax:
Mailing address:
  • Phone: 562-588-5143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number58679
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: