Provider Demographics
NPI:1891683918
Name:BUSTOS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S SUMMIT ST
Mailing Address - Street 2:STE: A
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112
Mailing Address - Country:US
Mailing Address - Phone:386-698-3796
Mailing Address - Fax:386-698-4675
Practice Address - Street 1:405 S SUMMIT ST STE A
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-3048
Practice Address - Country:US
Practice Address - Phone:386-698-3796
Practice Address - Fax:386-698-4675
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy