MEDICARE: BLANDINE B BUSTAMANTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	01042290A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093799546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLANDINE B BUSTAMANTE M.D.

Provider Business Mailing Address
First Line	:	2458 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5406
Country	:	US
Telephone Number	:	260-424-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 RANDALLIA DR
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46805-4638
Country	:	US
Telephone Number	:	260-424-2195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	04/29/2010

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