Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | DC14561 | CA |
Y | 213ER0200X | Radiology | DC14561 | CA |
NPI | 1093939555 |
---|---|
Provider Name | Dr. Gary Lloyd Bustin |
First Address | San Dimas, CA 91773-0304 |
Second Address | San Dimas, CA 91773-2630 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2007 |
Last Update Date | 08/07/2007 |