Healthcare Provider Details

I. General information

NPI: 1417001512
Provider Name (Legal Business Name): JOSEPH M BUSTAMANTE III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 W KING ST
OWOSSO MI
48867-2120
US

IV. Provider business mailing address

1031 E SAGINAW ST
LANSING MI
48906-5519
US

V. Phone/Fax

Practice location:
  • Phone: 517-487-5585
  • Fax: 517-487-1129
Mailing address:
  • Phone: 517-487-5585
  • Fax: 517-487-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5101010368
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: