Healthcare Provider Details

I. General information

NPI: 1275635559
Provider Name (Legal Business Name): DORIS V PABLO-BUSTOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DORIS PABLO-BUSTOS MD PC

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 VARNUM ST NE PMB 202
WASHINGTON DC
20017-2151
US

IV. Provider business mailing address

1140 VARNUM ST NE PMB 202
WASHINGTON DC
20017-2151
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-6430
  • Fax: 202-269-6598
Mailing address:
  • Phone: 202-269-6430
  • Fax: 202-269-6598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0101056019
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD30307
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberD0058776
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberMD30307
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number0101056019
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMD30307
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0101056019
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberD0058776
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMD30307
License Number StateDC
# 10
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number0101056019
License Number StateVA
# 11
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberD0058776
License Number StateMD
# 12
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberMD30307
License Number StateDC
# 13
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number0101056019
License Number StateVA
# 14
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberD0058776
License Number StateMD
# 15
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD30307
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: