Provider Demographics
NPI:1154439420
Name:BUSTAMANTE, IRINEO JR (MD)
Entity Type:Individual
Prefix:
First Name:IRINEO
Middle Name:
Last Name:BUSTAMANTE
Suffix:JR
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:440-717-6600
Mailing Address - Fax:
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-345-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04155400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ30035362OtherKEYSTONE MERCY
NJ60018849OtherHORIZON NJ HEALTH
NJP00312204OtherRAILROAD MEDICARE
NJ0212820000OtherAMERIHEALTH
NJ3987302Medicaid
NJ3987302Medicaid
NJ501395UKEMedicare PIN
NJBB04899220OtherDEA