Healthcare Provider Details

I. General information

NPI: 1316467756
Provider Name (Legal Business Name): STEPHANIE BUSTROS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N KEENE ST
COLUMBIA MO
65201-8369
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-1515
  • Fax: 573-884-0070
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2022049679
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number2022049679
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: