Healthcare Provider Details

I. General information

NPI: 1417017823
Provider Name (Legal Business Name): NEUROLOGY CONSULTANTS OF SOUTH FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 W 16TH AVE SUITE 100
HIALEAH FL
33012-5853
US

IV. Provider business mailing address

PO BOX 126629
HIALEAH FL
33012-1610
US

V. Phone/Fax

Practice location:
  • Phone: 305-826-5655
  • Fax: 305-826-5598
Mailing address:
  • Phone: 305-826-5655
  • Fax: 305-826-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberME58534
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME58534
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberME58534
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberME58534
License Number StateFL

VIII. Authorized Official

Name: DR. MARTHA BUSTAMANTE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 305-826-5655