Basic Information
| Provider Information | |||||||||
| NPI: | 1821317579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTOS MUNOZ | ||||||||
| FirstName: | SERGIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157788513 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 368 NE FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320553088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862928000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2010 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | ME128466 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | FTL# 43665 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | P2964 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80287531 | 05 | NM | MEDICAID | 284782403 | 05 | TX | MEDICAID | 200398620 A | 05 | OK | MEDICAID | 284782401 | 05 | TX | MEDICAID | 284782404 | 05 | TX | MEDICAID | 284782402 | 05 | TX | MEDICAID |