Provider Demographics
NPI:1275527749
Name:BUSTILLO LOPEZ, ANDRES (MD)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:BUSTILLO LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 S RED RD
Mailing Address - Street 2:SUITE 602
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3622
Mailing Address - Country:US
Mailing Address - Phone:305-663-3380
Mailing Address - Fax:786-533-1535
Practice Address - Street 1:6705 S RED RD
Practice Address - Street 2:SUITE 602
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3622
Practice Address - Country:US
Practice Address - Phone:305-663-3380
Practice Address - Fax:786-533-1535
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91869207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275991800Medicaid
FL275991800Medicaid
FLI36934Medicare UPIN