Provider Demographics
NPI:1164743837
Name:BUSTAMANTE, RAFAEL MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:MIGUEL
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 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-320-3380
Mailing Address - Fax:954-320-3371
Practice Address - Street 1:1601 S ANDREWS AVE FL 3
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2509
Practice Address - Country:US
Practice Address - Phone:954-320-3380
Practice Address - Fax:954-320-3371
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN14979390200000X
FLME1372332086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program