Provider Demographics
NPI:1063468304
Name:BUSTAMANTE, PETER JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JEROME
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13450 N MERIDIAN ST STE 354
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13450 N MERIDIAN ST STE 354
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1486
Practice Address - Country:US
Practice Address - Phone:317-338-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060754A207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200826270Medicaid
IN200311740HMedicaid
IN000000658340OtherANTHEM PIN
IN205110OtherMEDICARE GROUP
INM400020487OtherMEDICARE INDIVIDUAL
IN11581934OtherCAQH
IN200826270Medicaid
IN248600GMedicare PIN