=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477757334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO BUSTAMANTE MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 01/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12770 CIMARRON PATH SUITE 132
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78249-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-733-1802
-----------------------------------------------------
Fax | 210-733-1808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12770 CIMARRON PATH SUITE 132
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78249-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-733-1802
-----------------------------------------------------
Fax | 210-733-1808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. LETICIA A CANTU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-733-1802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | C14004
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------