Basic Information
| Provider Information | |||||||||
| NPI: | 1619472396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | LILIANA | ||||||||
| MiddleName: | DIAZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14850 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914024618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187872222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14850 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914024618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187872222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.