Provider Demographics
NPI:1861582652
Name:BUSUTTIL, ROBERT LEONARD (ABC CO BOC BOCPO)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEONARD
Last Name:BUSUTTIL
Suffix:
Gender:M
Credentials:ABC CO BOC BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 ERVILLA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767
Mailing Address - Country:US
Mailing Address - Phone:909-629-7615
Mailing Address - Fax:
Practice Address - Street 1:367 ERVILLA ST
Practice Address - Street 2:SUITE A
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-629-7615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC10438332BC3200X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment