Individual
BLANDINE B BUSTAMANTE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2200 RANDALLIA DR, FT WAYNE, IN 46805-4638
(260) 424-2195
Mailing address
2458 LAKE AVE, FORT WAYNE, IN 46805-5406
(260) 424-2195
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
01042290A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200002580
—
IN
Enumeration date
11/29/2005
Last updated
04/29/2010
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