Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | ME69798 | FL |
NPI | 1023019833 |
---|---|
Provider Name | Juan Bustillo |
First Address | Fort Myers, FL 33902-0001 |
Second Address | Fort Myers, FL 33912-4461 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2005 |
Last Update Date | 17/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
379937900 | (05) | FL |