Healthcare Provider Details

I. General information

NPI: 1386693679
Provider Name (Legal Business Name): PEDRO I. BUSTILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

IV. Provider business mailing address

8334 SW 85TH TER
MIAMI FL
33143-6973
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-3180
  • Fax: 305-575-3226
Mailing address:
  • Phone: 305-274-8583
  • Fax: 305-575-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number10,621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: