Provider Demographics
NPI:1306032263
Name:BUSTILLO CANCIO, JORGE A (MD)
Entity Type:Individual
Prefix:
First Name:JORGE A
Middle Name:
Last Name:BUSTILLO CANCIO
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:J66 CALLE COLMENAR
Mailing Address - Street 2:VILLA ANDALUCIA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2524
Mailing Address - Country:US
Mailing Address - Phone:787-430-5471
Mailing Address - Fax:
Practice Address - Street 1:J66 CALLE COLMENAR
Practice Address - Street 2:VILLA ANDALUCIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-2524
Practice Address - Country:US
Practice Address - Phone:787-430-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16909208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice